Glengariff Health Care Center

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs. This was evident for five of seventeen residents reviewed for psychoactive medications in a total of 30 records reviewed. Specifically, 1) Resident #19 received Xanax used to decrease anxiety 32 times between January and April 2011, 2) Resident #30 received Ativan also used to decrease anxiety 12 times between September and October 2010, 3) Resident #24 received 37 doses of Haldol used for psychotic disorders, 4) Resident #11 received three doses of Ativan and 5) Resident #29 received Ativan 39 times between September and December 2010. These medications were administered without documented evidence of non-pharmacological interventions attempted prior to administration. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding includes but is not limited to:

1) Resident #19 has diagnoses that include Dementia and Anxiety Disorder.

The Minimum Data Set (MDS) Assessment dated 8/19/10 documented the resident's cognition as moderately impaired. The MDS also documented mood and behavior patterns for Resident #19 which included sad, worried facial expressions and resistance to care.

Review of the Comprehensive Care Plan (CCP) for Behavioral symptoms dated 8/26/10 documented that the intensity, duration and frequency of the behavior should be documented in the progress notes.

Physician's orders dated 1/3/11 documented an order for Xanax 0.25 milligram (mg) by mouth at 9:00 AM and at 2:00 PM. The order also documented to administer 0.25 mg by mouth every 4 hours as necessary (prn) for Anxiety.

The e Medication Administration Record (MAR) dated January 2011 was reviewed. The MAR documented that the prn Xanax had been administered 6 times in addition to the 9:00 AM and 2:00 PM dose.
The e MAR dated February 2011 documented that prn Xanax had been administered 14 times.
The e MAR dated March 2011 documented that the prn Xanax had been administered 6 times.
The e MAR dated April 2011 documented that the prn Xanax had been administered 7 times.

There was no documented evidence in the medial record, or behavior notes documenting the behavior that Resident #19 was exhibiting prior to the administration of the Xanax. There was also no documented evidence as to the effectiveness of the medication after it had been administered.

On 4/13/11 at 10:45 AM the Registered Nurse (RN) Supervisor where Resident #19 resided was interviewed. The RN stated that behavior notes did not need to be written for this resident because it was not an abnormal behavior for her. The RN further stated that the resident asked to go to the bathroom, she misses her family and the Xanax makes her comfortable.

On 4/14/11 at 10:30 AM the physician responsible for Resident #19 was interviewed. The physician stated that he would expect non-pharmacological interventions to be attempted prior to administering the Xanax. The physician further stated that the staff knows the resident well and he was sure that alternative measures were being attempted.

On 4/14/11 at 10:45 AM the Psychiatrist was interviewed. The Psychiatrist stated that for Resident #19 he would not expect that any alternative interventions would be attempted by nursing prior to administering the Xanax.

2) Resident #30 has diagnoses that include Dementia and Anxiety Disorder.

The MDS dated 9/12/10 documented the resident's cognition as moderately impaired. The MDS also documented that the resident exhibited persistent anger, wandering and resistance to care.

Physician's orders dated 8/16/10 documented that the resident was to receive Ativan 0.5 mg by mouth every 6 hours prn for Senile/Presenile Psychosis. Additionally, the resident received Trazodone (antidepressant) 25 mg by mouth at 12:00 PM and 9:00 PM and Seroquel (an antipsychotic used for acute manic episodes) 50 mg by mouth at hour of sleep.

The eMAR's documented that Ativan had been administered 5 times in September 2010 and 7 times in October 2010.

A review of nurse's notes for September and October 2010 revealed no documented evidence as to why Resident #30 had received the prn Ativan. There was also no documented evidence as to what specific behavior was being altered.

On 4/15/11 at 10:30 AM the Assistant Director of Nursing (ADNS) was interviewed. The ADNS stated that there were no behavior notes documented in the medical record for this resident prior to the administration of the prn Ativan. The ADNS stated that there should have been documentation and she would check with the RN Supervisor as to why there was no documentation.

On 4/15/11 at 10:50 AM the RN Supervisor where Resident #30 had resided was interviewed. The RN stated that Resident #30 could not be re-directed. The resident believed, that he could ambulate and he was resistive to care at times and combative with staff.

3) Resident # 24 was readmitted to the facility on 1/10/11 and had diagnoses including Dementia with Behavioral Disturbances and Depressive Disorder.

An MDS dated 2/3/11 documented that the resident had long and short term memory problems and was moderately impaired in cognitive skills for daily decision making. The MDS further documented that the resident exhibited behaviors including physical and verbal symptoms directed toward others and rejection of care.

An active CCP dated 11/12/10, titled Behavior, documented to provide frequent reminders and redirection, as needed.

An active CCP dated 8/5/10, titled Psychotropics, documented to redirect resident to a quiet area when exhibiting episodes of disruptive behavior and agitation.

A Physician's Order dated 1/13/11 documented to give Haloperidol (Haldol) (an antipsychotic) 0.5 mg every morning and Haldol 1 mg at 12 noon and 6 PM.

A Physician's Order dated 2/7/11, and renewed on 3/7/11 and 4/4/11, documented to increase the Haldol to 1 mg every morning and continue with Haldol 1 mg at 12 noon and 6 PM.

Additionally, a Physician's Order dated 1/13/11 and renewed on 2/7/11, 3/7/11 and 4/4/11 documented Haldol 5 mg/ml (milligrams per milliliter)
Injection, inject 1 mg or give 1 mg by mouth every 6 hours as needed for Dementia with Behavioral Disturbances.

The eMAR's documented that prn Haldol had been administered 3 times in January 2011, 11 times in February, 17 times in March and 9 times in April 2011.

There was no documented evidence on the MAR's noting the behaviors that Resident #24 had exhibited prior to the prn Haldol being administered, alternative interventions attempted prior to the administration of the prn Haldol or the effectiveness of the prn Haldol.

Behavior notes dated 2/11/11 through 4/15/11 were reviewed. There was no documented evidence on the Behavior Notes indicating the behaviors that Resident #24 had exhibited prior to the prn Haldol being administered, alternative interventions attempted prior to the administration of the prn Haldol or the effectiveness of the prn Haldol.

The Licensed Practical Nurse (LPN) Medication Nurse was interviewed on 4/15/11 at 11:15 AM. The LPN stated that alternative interventions are attempted with Resident #24 prior to the administration of the prn Haldol, but it is not always documented. The LPN further stated that if Resident #24 is extremely agitated, the prn Haldol would be given as it does calm the resident down.

The RN Charge Nurse was interviewed on 4/15/11 at 11:00 AM. The RN stated that some behaviors are documented, but not with each administration of the prn Haldol, because these are not new behaviors with this resident. The RN further stated that she was unaware that documentation of alternative interventions would be required with each administration of the prn Haldol.

The Policy/ Procedure P/P (Titled) Psychotropic Medications dated 6/08 was reviewed. The P/P documented that behavior notes must show: a) "specific behavior i.e., agitation, physical aggression, yelling (must indicate if disruptive to other), wandering, disrobing, lethargic and/or crying. b) What kind of interventions were employed, i.e., 1 to 1 intervention, speak in a calm voice-moved resident to a quiet area , redirected into program. c) if intervention is effective or not".

415.12(l)(1)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that all residents received the necessary care and services to maintain their highest practicable physical, mental and psychosocial well-being in accordance with their plan of care. 1) This was evident for 5 of 17 residents reviewed for pain in a total of 30 sampled residents. Specifically, Residents #3, #4, #6, #12 and #14 were identified to have pain and had received multiple doses of pain medication, without documented assessments and reassessments as to the effectiveness of the medication administered. 2)This was also evident for 1 of 6 resident's reviewed for Pacemakers (Resident # 29). Specifically, Resident #29 was admitted with a pacemaker with no documented evidence that the pacemaker was assessed, care planned for or that pacemaker checks had been completed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings include but not limited to:

1a) Resident #3 was admitted to the facility on 3/31/11 with diagnoses including Hip Joint Replacement and Chronic Pain.

The Admission Minimum Data Set (MDS) Assessment dated 4/10/11 documented that the resident was cognitively intact. The MDS also documented that when the resident was asked about the intensity of the pain, over the past 5 days during the assessment period the resident stated that she had frequent pain. The resident also stated that the pain made it difficult to sleep at night. The pain intensity was rated "8" over the last 5 days of the assessment period on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine.

The Medical Admission-Readmission Evaluation dated 4/1/11 documented that the resident had a history of chronic pain and was in significant pain at the time of admission.

A Pain Assessment dated 3/31/11 documented that the resident had pain intensity at level 8 (highest possible level 10, on a numeric rating scale of 0-10).

The Physician's Orders dated 3/31/11 documented the following:

Dilaudid (an opioid pain reliever) 2 milligrams (mg.) by mouth every 4 hours as needed for mild pain.

Dilaudid 4 mg. by mouth every 4 hours as needed for moderate pain.

Dilaudid 8 mg. by mouth every 3 hours as needed for severe pain.

The electronic Medication Administration Record (eMAR) from 4/1/11 through 4/12/11 documented that Dilaudid 2 mg. was administered once, Dilaudid 6 mg. was administered 3 times and Dilaudid 8 mg. was administered 47 times without pre or post pain assessments.

Review of Nurse's Notes from 4/1/11 through 4/12//11 documented that Resident #3 was medicated for pain with relief noted between 4/1/11 and 4/12/11 for a total of six times There was no documented evidence that a pain assessment had been completed to determine the degree of discomfort prior to the administration or after the pain medication was administered to ensure relief.

The Licensed Practical Nurse (LPN) Medication Nurse was interviewed on 4/13/11 at 11:40 AM. The LPN stated that the level of pain prior to administration of pain medications and the effectiveness of the pain medication is assessed, but would be documented only if monitoring had been ordered by the physician.

The Associate Director of Nursing Services (ADNS) was interviewed on 4/13/11 at 11:05 AM. The ADNS stated that the level of pain prior to administration of pain medications and the effectiveness of the pain medication should have been documented on the eMAR with each administration.

An interview was conducted on 4/14/11 at 9:05 AM with the Medical Director. The Medical Director stated that the nursing staff should document the effectiveness every time a PRN pain medication is administered.

1b) Resident #12 was readmitted on 11/10/10 with diagnoses including Fracture of the Femur and Generalized Pain.

A Physician's Order dated 11/10/10 through 1/4/11 documented Percocet (an opioid pain reliever) 5 mg-325 tablet, one tablet by mouth every four hours as needed for pain in joint.

The Comprehensive Care Plan (CCP) developed for Pain updated 12/13/10 documented an intervention that included assessment of pain characteristics: quality, onset, precipitating/relieving factors, location and severity using numerical or face pain rating scale.

A review of the eMAR from November 2010 thru January 2011 documented that Resident #12 received Percocet 27 times in November, 19 times in December and 7 times in January without pre and post pain assessments.

A review of the electronic Nurses' Progress Notes from 11/10/10 through 1/4/11 contained no documented evidence of pre and post pain assessments when Percocet was administered.

The facility's Policy and Procedure dated 11/08 titled Pain Assessment Management documented "...Staff will assess the medication for effectiveness in management of pain, dosage and administration intervals."

2) Resident # 29 has diagnoses that include Atrial Fibrillation, Chronic Ischemic Heart Disease and Cardiac Pacemaker.

The MDS Assessment dated 5/8/10 documented that the resident had moderately impaired cognition.

The initial nursing assessment completed by a Registered Nurse (RN) on 4/26/10 did not identify the presence of the pacemaker. The Patient Review Instrument (PRI) that the facility received upon initial admission dated 4/23/10 was reviewed. The PRI documented the presence of the pacemaker. The RN Supervisor stated that the RN that completed the initial admission assessment should have notified the physician to obtain the order for the pacemaker checks.

A review of the medical record revealed no documented evidence that the physician had ordered pacemaker checks. Additionally, there was no CCP developed for the pacemaker.

On 4/15/11 at 1:00 PM the Director of Nursing Services (DNS) was interviewed. The DNS verified that the closed medical record contained no evidence that a pacemaker check had been completed for this resident.

On 4/15/11 at 1:15 PM the 7:00 AM- 3:00 PM RN Supervisor was interviewed. The RN contacted the company responsible to complete the pacemaker checks and reported that there was no record of Resident #29 having had a pacemaker check since admission 4/26/10. The RN was unable to state how this omission had occurred.

The Policy/Procedure (P/P) dated 6/08 titled Pacemaker Monitoring was reviewed. The P/P documented that pacemaker Monitoring will take place every 3 months unless otherwise ordered by the physician.

415.12

Based on observation, staff interview and record review during the recertification survey, the facility did not store food, and maintain the kitchen environment under safe and sanitary conditions to prevent food borne illnesses. Reference is made to the following:

1. The storage of food items directly on the floor and the storage of a non kitchen food item (fish food) in the kitchen.
2. Lint accumulation on a pot drying rack and an accumulation of an unknown white substance on a food storage rack.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During an inspection of the kitchen on 4/11/11 between 7:00am and 7:45am the following was noted:

1. Six boxes of "sweet butter cream" and two boxes of "coronation" chicken were stored directly on the floor (beneath two storage racks) in the walk-in freezer. A plastic container of "fish food" was also observed stored on a storage rack in the same freezer.

In an interview at approximately 8:00am the Food Service Supervisor stated that the items are not supposed to be stored directly on the floor and immediately removed them. He also stated the fish food would be stored in a separate area away from the kitchen.

2. An accumulation of lint was observed on portions of three shelves of a drying rack in the pot washing area. An accumulation of an unknown white substance was observed on portions of two shelves of a storage rack in the walk-in freezer.

In an interview on the same day at approximately 8:05am the Food Service Supervisor stated that storage shelves are cleaned weekly and as needed. He further stated that all the identified accumulation would be cleaned.

NYCRR 415.14(h)
Chapter 1 SSC Subpart 14-1

Based on observations, staff interviews and record review during the recertification survey, the facility did not establish and maintain an Infection Control Program, including staff washing their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. This was evident for one of 2 residents (Resident #16) observed for infection control in a total of 30 sampled residents. Specifically, for Resident #16, during a treatment observation, the Licensed Practical Nurse (LPN) was observed to remove the soiled dressing from a pressure ulcer site and, with the same gloved hands, proceed to touch the wound care tray contents without removing her gloves and washing her hands. This resulted in no actual harm with a potential for more than minimal harm which is not an immediate jeopardy.

The finding is:

Resident #16 has diagnoses including Dementia and Stage III Pressure Ulcer (P/U) to the Right Heel .

The Physician Order dated 4/5/11 documented to cleanse right heel with Normal Saline Solution and apply Aquacel covered with Dry Sterile Dressing (DSD) daily for P/U.

During a P/U treatment observation on 4/13/11 at 8:30 AM the LPN was observed to wash her hands and don gloves. The LPN removed the resident's heel booties, turned the resident and placed a pillow to position him on his side. She then lifted his right foot, removed the band aide holding the ace bandage to the heel, unwrapped the ace bandage and removed the DSD applied to the wound. The dressing was noted to be soiled with bloody drainage. The LPN proceeded to remove the sealed paper lid of the wound care tray, and manually took the contents (including the 4 x 4 gauze pads, a pair of scissors, and a normal saline bottle) and placed these on the sterile field. The LPN was observed to then remove her gloves, wash her hands and don clean gloves. The LPN then completed the treatment using the now contaminated contents of the wound care tray.

In an interview with the LPN at 9:15 AM she stated that she did not realize that she should have washed her hands after removing the soiled dressing and before touching the wound care tray and its contents.

In an interview with the Infection Control Nurse on 4/13/11 at 11:00 AM she stated that the LPN had contaminated the contents of the wound care tray and would be inserviced for correct infection control procedures.

415.19(a)(1-3)

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that each resident receives adequate supervision to prevent accidents. This was noted for one resident (#21) in a total of 30 sampled residents. Specifically, during toileting, the resident was left unattended by the Certified Nursing Assistant (CNA), resulting in the resident's fall causing an abrasion to the nasal area and laceration and hematoma to mid forehead. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #21 has diagnoses including Hypertension, Epilepsy and Dementia

An annual Minimum Data Set (MDS) assessment dated 12/13/10 documented the resident to have memory problems and moderately impaired cognition. The MDS also documented that the resident had inattention (difficulty focussing attention-easily distracted, out of touch or difficulty following what was said). The resident required extensive assistance of one person for transfers. It also documented that the resident was not steady (only able to stabilize with assistance) while moving from seated to standing position and while moving on and off toilet.

A Comprehensive Care Plan (CCP) for Activities for Daily Living updated on 7/20/10 documented that the resident required extensive assistance of one for walking on unit and extensive assistance of one for toileting.

An Incident Report (IR) documented that a fall was sustained by the resident on 1/26/11 at 1:55 AM in the bathroom. The IR documented the resident's condition before the accident to be forgetful and with some confusion.

The IR documented description of the incident, "Resident screamed for help, staff found patient with face down inside the bathroom. Sustained abrasion on nasal area and Hematoma and small laceration to mid forehead. Unable to state what happened due to mental status. Patient was toileted by staff and wanted to close the bathroom door and refused to be assisted."

The Nursing progress notes documented that the resident was transferred to the Emergency Room at 7:12 AM for evaluation and management and returned with 2 sutures to the forehead.

The 11:00 PM-7:00 AM CNA was interviewed on 4/14/11 at 3:00 PM. The CNA stated that the resident was not regularly assigned to her and she might have been assigned for her care for the night of 1/26/11 only. The CNA stated she heard the resident's bed alarm ring and took the resident to the bathroom and put her on the toilet. The CNA further stated that since the incident occurred a while ago she did not remember more details about it.

The 11:00 PM-7:00 AM unit charge LPN was interviewed on 4/15/11 at 10:00 AM. The LPN stated that the resident's room is situated close to the Nursing Station and the CNA and herself had heard the resident's bed alarm. The LPN stated that the CNA had helped the resident into the bathroom. The LPN also stated that she heard the resident yelling at the CNA to get out and close the door. The LPN stated that she had showed the resident the location of the call bell and told the resident to call when she was ready. The LPN further stated that she had instructed the CNA to stay outside of the bathroom door. The LPN stated that the resident had a right to privacy.

The Director of Nursing Services (DNS) was interviewed on 4/15/11 at 10:00 AM and stated that she did not see anything negative in the LPN's decision to leave the resident unattended.

The Physician was unavailable for comment.

415.12(h)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure the timely implementation of the necessary measures for a resident to prevent dehydration and medical complications. Specifically, Resident #5 had a Physician's STAT (immediately) order for a Blood Urea Nitrogen (BUN) (an indicator of hydration status) and Creatinine levels (measures to assess the adequacy of the daily fluid intake and renal function). The elevated BUN and Creatinine levels were not reported timely to the Physician. This was evident for 1 (Resident #5) of 2 reviewed for hydration concerns in a total sample of 30 residents. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #5 has diagnoses that include Congestive Heart Failure, Alzheimer's Disease and Dehydration.

The Minimum Data Set (MDS) Quarterly Assessment dated 3/2/11 documented that the resident was severely impaired in cognition and required limited assistance of one person in eating. The MDS also documented that the resident had a weight loss and was not on a Physician's restricted weight loss program.

The electronic (e) Physician's Progress Note dated 3/2/11 documented that the resident was not eating and that the BUN was 31 milligram per Deciliter (mg/Dl) (normal range 7 - 23) and Creatinine was 1.02 mg/Dl (normal range 0.50-1.30).

The e Physician's Order dated 3/7/11 documented that Lasix (a diuretic) was renewed at 40 mg by mouth once daily.

The e Nursing Progress Note dated 3/29/11 at 10:39 AM documented that the resident had poor appetite and that the Physician saw the resident and ordered an STAT order for Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP helps evaluate kidney and liver function, sugar and protein levels in blood and electrolytes and fluid balance). Urinalysis (U/A) and Culture and Sensitivity (C/S).

The e Physician's Progress Note dated 3/29/11 documented that the resident had very poor appetite and ordered CBC, CMP, U/A and C/S.

The Laboratory Report dated 3/29/11 documented that the resident's blood specimen was collected at 12:29 PM and a fax copy was printed and sent at 2:06 PM. The Laboratory Report documented that the resident's BUN level was high at 75 mg/Dl and Creatinine was high at 1.80 mg/Dl.

The e Nursing Progress Note dated 3/29/11 at 1:54 PM documented that the Stat blood work was completed.

The e Nursing Progress Note reviewed from 3/29/11 at 1:54 PM through 3/30/11 at 2:59 PM did not contain documented evidence that the Physician was notified of the STAT laboratory orders revealing a high BUN, and a high Creatinine levels.

The Laboratory Provider was interviewed on 4/15/11 at 8:45 AM. The Provider stated that the resident's blood specimen was collected on 3/29/11 at 12:29 PM and that the results were called STAT to the facility on 3/29/11 at 2:05 PM and faxed on 3/29/11 at 2:06 PM.

The Registered Nurse (RN) Nurse Practitioner (NP), who received the call and faxed laboratory report from the Laboratory Provider, was interviewed on 4/15/11 at 10:00 AM. The NP initially stated that she was not the person who received the laboratory report and later recanted. The NP stated that she only received the call and faxed laboratory report and handed the report immediately over to the Unit Charge Nurse.

The Attending Physician, who ordered the STAT laboratory orders on 3/29/11, was interviewed on 4/15/11 at 10:40 AM. The Physician stated that he would have expected to be notified immediately of abnormal STAT laboratory results.

The RN Unit Charge Nurse was interviewed on 4/15/11 at 11:00 AM. The RN stated that she had received the faxed laboratory report from the NP and notified the Physician the next day of the results. The RN stated that the Physician should have been notified of the STAT laboratory order results immediately.

415.12(j)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accidents/Incidents (A/I's) were thoroughly investigated for 2 of 30 sampled residents reviewed for abuse, neglect or mistreatment. Specifically, 1) an A/I noted that Resident #19 was found with a large ecchymotic area on the lateral chest and breast area. The investigation was without statements from all assigned staff that cared for the resident surrounding the time period, and 2) Resident #29, three A/I's were without statements from assigned staff. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #19 has diagnoses that include Hypertension and Dementia.

The Minimum Data Set (MDS) Assessment dated 2/7/11 documented the resident as having moderately impaired cognition. The MDS also documented the resident as needing extensive assist of one person for transfer.

An A/I report dated 3/29/11 at 10:00 PM documented that while the Certified Nursing Assistant (CNA) was putting Resident #19 into bed she observed a large ecchymotic area on the right lateral chest and breast area. The A/I report had no documentation as to the measurements of the ecchymotic area.

Statements obtained from assigned staff on shifts previous to the identification of the ecchymotic area were limited to documenting that the resident had either been assisted into or out of the bed. There were no statements as to the care that had been rendered to the resident.

2) Resident #29 has diagnoses that include Hypertension and Depression.

The MDS Assessment dated 9/29/10 documented the resident's cognition as moderately impaired. The MDS also documented that the resident required limited assistance of one person for transfer.

An A/I report dated 9/16/10 at 9:15 PM documented that a large ecchymotic area 12 centimeters (cm) x 3 cm was observed on the outer aspect of the right thigh. The investigation contained statements from assigned staff that the resident had been assisted into or out of bed. There were no statements pertaining to any specific care the resident might have received on that particular shift.

An A/I report dated 10/16/10 at 7:30 AM documented that the resident was observed with an ecchymotic area to the left lower forearm. The investigation contained no statements from assigned staff who had cared for the resident on previous shifts.

An A/I report dated 11/13/10 at 12:15 AM documented that the Registered Nurse (RN) responded to a chair alarm for Resident #29. The resident was found in her room with her locked wheelchair flipped backwards. The resident sustained a laceration 1 inch to the back of the head with hematoma and swelling noted. There were no statements obtained from the assigned CNA on the 11:00 PM- 7:00 AM shift or the 3:00 PM- 11:00 PM shift as to why the resident was in her wheelchair at 12:15 AM, or how long she had been in the chair.

On 4/11/11 at 8:15 AM the Assistant Director of Nursing (ADNS) was interviewed. The ADNS stated she is responsible to ensure that all A/I's are thoroughly investigated to rule out abuse, neglect or mistreatment. The ADNS stated that the form currently being utilized for the investigation into A/I's needed revision. The form does not ask the staff specific questions about the care that had been provided to the resident when an injury of unknown origin occurs.

415.4(b)(1)(ii)

Based on observations, staff interviews and record reviews during the recertification survey, the facility did not ensure that the Certified Nursing Assistants (CNAs) are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This was observed for one resident (#16) in a total of 30 sampled residents. Specifically, during a treatment observation an opened purpura (4.0 centimeter (cm) X 3.00 cm) was noted on the resident's right thigh, which had not been timely reported by the Certified Nursing Assistant (CNA). This resulted in no actual harm with a potential for more than minimal harm which is not an immediate jeopardy.

The finding is:

Resident #16 has diagnoses including Dementia, Hypertension and Stage III Pressure Ulcer (P/U) to the right Heel .

During a P/U treatment observation on 4/13/11 at 8:30 AM, a 4 cm X 3 cm opened blister was observed on the resident's right thigh. The blister was noted to have a dried, broken skin flap adhering to the side with the exposed wound bed and was purplish dark in color.

The medical record including the Physician's orders, Nursing and Medical progress notes, and Skin Care Plan, was reviewed. The skin tear to the right thigh was not documented.

The resident's 7:00 AM-3:00 PM CNA was interviewed on 4/13/11 at 1:00 PM and stated that she had been assigned to take care of the resident since beginning of April, 2011. The CNA stated that developing skin tears is an ongoing issue for this resident, therefore she does not focus or pay much attention to it. She stated that she did notice a blister on the resident's left upper arm, and reported that to the nurse yesterday. The CNA further stated that she did not notice the skin tear on the resident's thigh.

The wound Licensed Practical Nurse (LPN) observed the skin tear on 4/13/11 at 2:30 PM and stated that it was approximately 4 cm x 3 cm, opened skin tear, skin still attached and pushed over, purplish red in color, no drainage and could have opened a day or two ago.

The unit Charge LPN stated on 4/13/11 at 2:30 PM that a Physician's order was obtained at 2:00 PM to cleanse open purpura (R) thigh with normal saline solution and apply Bacitracin covered with Telfa and DSD daily X 7 days, then reassess.

415.26(c)(1)(iv)

Based on observations, record reviews and staff interviews during the recertification survey, the facility did not ensure that 1) opened and undated and expired multidose medication vials were removed from residents' units, and 2) that a system of records was maintained for the disposition of all controlled drugs. This was evident on 2 of 4 nursing units (Pratt 1 and Pratt 2) observed and one of 30 records reviewed (Resident #14). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1a) During an observational tour of the 1 Pratt Unit with the Licensed Practical Nurse (LPN) Charge Nurse on 4/11/11 at 8:30 AM, the following was noted:

Four opened and undated 10 milliliter (ml.) vials of Novolin R Insulin ( a medication for Diabetes) and one opened and undated 10 ml. vial of Compazine (a medication for nausea) were observed in the medication refrigerator.

The LPN was immediately interviewed and stated that any multidose vials should be dated by the medication nurse upon opening.

1b) During an observational tour of the 2 Pratt Unit with the LPN on 4/11/11 at 6:15 AM, the following was noted:

Two opened and undated 10 ml. vials of Novolin R Insulin was observed in the medication refrigerator and one opened 10 ml. vial of Lantus Insulin dated 2/24/11.

The 11:00 PM to 7:00 AM Registered Nurse (RN) Supervisor was interviewed at 6:30 AM. The RN stated that multidose Insulin vials should be dated when opened and that the expired Insulin vials should have been discarded.

The facility's policy dated 11/10 titled, "Drug Administration Injectable Multiple-Dose Vials" documented that the medication nurse will record the date of initial use upon preparation of the first dose drawn. The policy further documented that multidose vials are to be discarded 28 days after opening.

2) Resident #14 has diagnoses including Generalized Pain.

The Minimum Data Set (MDS) with Significant Change Assessment dated 4/1/11 documented that the resident was severely impaired in cognition and frequently in pain with a numeric rating of 5 (score 0-10, with 10 as the highest level of pain).

The Comprehensive Care Plan (CCP) developed for Pain dated 3/30/11 documented Duragesic (an opioid pain reliever patch) Patch 25 ugm/h every 72 hours.

The renewed Physician's Order dated 3/25/11 documented Duragesic (Fentanyl) 25 microgram per hour (ugm/h) Transdermal Patch apply patch every 3 days.

The Electronic Medication Administration Record (eMAR) reviewed from 2/15/11 through 4/13/11 documented that Duragesic Transdermal Patch was administered 14 times.

The Resident's Fentanyl Patch Narcotic Sheet reviewed from 2/15/11 through 4/13/11 revealed only 3 of 14 Fentanyl Patches, documented as disposed of, contained the required two licensed nursing staff signatures.

The RN Unit Charge Nurse was interviewed on 4/15/11 at 11:00 AM. The RN stated that used Fentanyl Patch must be disposed of in the presence of a witness. The RN further stated that the two licensed nursing staff signatures are recorded in the Resident's Fentanyl Patch narcotic sheet. The RN also stated that the Resident's Fentanyl Patch narcotic sheet reviewed from 2/15/11 through 4/13/11 should have two licensed nursing staff signatures when disposing the Fentanyl Patch.

The Director of Nursing Services (DNS) was interviewed on 4/15/11 at 11:10 AM. The DNS stated that disposal of Fentanyl Patches is done in the presence of a witness and should have two licensed nursing staff signatures when Fentanyl Patch disposal is documented.

The facility's policy dated 9/09 (Titled) Fentanyl Transdermal Patches for Pain Relief documented "... the used Fentanyl Patch should be disposed of in the presence of a witness. Therefore, when the patch is disposed of, two (2) nurses must sign that it was disposed of."

415.18(d)

Physical Plant Violations- State Only

713-2.21 Mechanical systems and equipment requirements

(d) Heating and ventilating systems shall comply with the following:

(2) All air-supply and air-exhaust systems shall be mechanically operated. All fans serving exhaust systems shall be located at the discharge end of the system. The ventilation rates shown in Table 8 shall be considered as minimum acceptable rates and shall not be construed as precluding the use of higher ventilation rates.

(viii) A manometer shall be installed across each filter bed serving central air systems.

Based on observation and staff interview, the facility did not provide required manometers across all filter beds serving central air systems in both the Glengariff building and Pratt Pavilion. This was noted in two of two buildings.

This resulted in no actual harm with potential for minimal harm that is not immediate jeopardy.

The findings are:

On 4/11/11 & 4/12/11 between 9:00am- 1:00pm during the recertification survey, it was noted that the facility has central air systems serving areas including but not limited to the rehabilitation area on the main level and the kitchen storage area in the vicinity of the service elevator in the lower level, both in the Pratt Pavilion. A manometer was not provided across the filter bed serving the rehabilitation area and the manometer across the filter bed for the kitchen storage area was observed not functional.

In an interview on 4/12/11 at approximately 1:00pm, the Director of Maintenance stated that there are no manometers installed across filter beds on central air systems in either the Glengariff building or the Pratt Pavilion. He further stated that the manometers will be installed immediately.

Based on record review and staff interview during the recertification survey, the facility did not ensure that a Surety Bond was held by the facility to cover the amount of monies in the resident's personal funds being held by the facility. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

As provided by the facility's Business Office, the total balance of the residents' personal funds as of 4/14/11 totaled $97,713,40.

An interview with the facility Administrator was conducted on 4/14/11 at 10:00 AM. The Administrator stated that he was not able to produce evidence that the facility had obtained a Surety Bond. The Administrator further stated that he had requested the paper work to initiate the process for obtaining a Surety Bond .

483.10(c)(7)

Based on observation, record reviews and staff interviews during the recertification survey, the facility did not ensure that charges were not imposed for items determined as necessary by the facility and not requested by the resident/family. This was noted for 3 of 4 residents reviewed for security-suit/jumpsuits in a total of 30 sampled residents. Specifically, a review of the monthly financial statements for Residents #5, #17 and #36 documented that charges were made to the resident's personal fund to purchase jumpsuits. This resulted in no actual harm with the potential for minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #5 has diagnoses including Dementia and Alzheimer's Disease.

The Minimum Data Set (MDS) Quarterly Assessments dated 12/17/10 and 3/2/11 documented that the resident was severely impaired in cognition and required limited assistance of one person for toilet use and personal hygiene.

The resident was observed on 4/13/11 at 10:00 AM lying in bed. The resident stated that she wears a jumpsuit when she is Out of Bed (OOB).

The Comprehensive Care Plan (CCP) developed for Physical Restraint dated 3/11/11 documented that the resident was to wear a one piece jumpsuit to prevent the resident from smearing feces due to inability to comprehend appropriate behavior due to Dementia.

An apparel company invoice for Resident #5 dated 2/10/11 documented a charge of $106.00 for 2 jumpsuits. A subsequent apparel company invoice for Resident #5 dated 3/7/11 also documented a charge of $148.00 for 3 jumpsuits.

A Physician's Order dated 4/12/11 documented a one piece suit to prevent the resident from smearing feces due to inability to comprehend appropriate behavior secondary to Dementia.

A review of the facility's Resident Trust Funds Statement documented that Resident #5's personal account was charged $106.00 on 3/16/11 for 2 jumpsuits and $148.00 on 3/31/11 for 3 jumpsuits.

2) Resident #36 has diagnoses including Dementia, Psychosis and Depressive Disorder.

The resident was observed in the dining room in a recreation activity on 4/13/11 at 10:35 AM wearing a jumpsuit.

The unit Charge Licensed Practical Nurse (LPN) was interviewed on 4/13/11 at 10:40 AM. The LPN stated that the resident has a Physician's order effective 3/11/10 and a CCP for the use of a jumpsuit to prevent the resident from smearing feces. She further stated that the jumpsuit is being used for the resident both night and day.

An apparel company invoice for Resident #36 dated 8/30/10 documented a charge of $187.00 for 6 jumpsuits.

A review of the facility's Resident Trust Funds Statement documented that Resident #36's personal account was charged $187.00 on 9/20/10.

3) Resident #17 has diagnoses including Senile Dementia, Depression and Insomnia.

The resident was observed in recreation on 4/13/11 at 10:35 AM wearing a jumpsuit.

The Physician's orders dated 5/20/10 and the CCP for restraints documented the use of a jumpsuit to prevent the resident from disrobing since 5/2010.

An apparel company invoice for Resident #17 dated 7/15/10 documented a charge of $179.00 for 4 jumpsuits.

A review of the facility's Resident Trust Funds Statement documented that Resident #17's personal account was charged $179.00 on 9/1/10.

On 4/15/11 at 12:00 PM the Social Work (SW) Director was interviewed The SW Director stated that she was aware that the facility was purchasing the jumpsuits with the resident's personal funds. The SW Director further stated that a jumpsuit is a part of the residents wardrobe and categorized as general clothing and the facility does not provide the residents wardrobe.

415.26(h)(5)(vi)

Based on observation and staff interview, the spacing between rails of provided guards on 2nd floor stair landings in the Glengariff building and Pratt Pavilion were greater than the required four inches. This was noted on the 2nd floor landings of six of six stairwells in the Glengariff building and Pratt Pavilion.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 4/12/11 between 8:30am- 2:00pm during the recertification survey, it was noted that guards were provided on all 2nd floor stair landings in both the Glengariff building and the Pratt Pavilion. The following was noted:

1) The spacing between the rails of the guards on the 2nd floor landings of the East, West and Center stairs of the Glengariff building were approximately 17inches between the top rail, middle rail and the concrete landing.

2) The spacing between the rails of the guards on the 2nd floor landings of the North, South and East stairs of the Pratt Pavilion were approximately 15inches between the top rail, middle rail and the concrete landing.

In an interview on 4/12/11 at approximately 1:15pm, the Director of Maintenance stated that he will address the issue immediately.

711.2(a)(1), 483.70(a), 2000 NFPA 101: 7.2.2.4.1, 7.2.2.4.6, 19.2.2.3, 19.2.2.4.