Albany County Nursing Home

Deficiency Details, Certification Survey, December 18, 2012

PFI: 0030
Regional Office: Capital District Regional Office

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Z310 415.29: PHYSICAL ENVIRONMENT

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

Citation date: December 18, 2012

Based on observation and staff interview during the standard recertification survey, it was determined that the facility did not provide protection to prevent the potential of contamination of the water supply. Specifically, 2 plumbing fixtures were found to have hoses connected to the water supply system that were lacking protection, such as vacuum breakers, to prevent the potential for back siphonage. This did not result in actual harm but had the potential for more than minimal harm. This is evidenced as follows:
During inspection observations of the main kitchen and resident area dining rooms on 12/12/2012 at 9:20 AM, a vacuum breaker was not plumbed into the water piping servicing the spray hose by the automatic dish washing machine; the nozzle of this hose can reach below the flood rim of the pre-rinse sink. And a vacuum breaker was not plumbed into the water piping servicing the spray hose by the middle steam jacketed kettle; the nozzle of this hose can reach below the flood rim of the steam jacketed kettle.
The Director of Food and Nutrition stated in an interview conducted on 12/12/2012 at 9:20 AM that the maintenance department would need to be contacted to plumb the vacuum breakers.

10 NYCRR 415.29(b), 713-1.18 (e) (2) (iii)

F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Citation date: December 18, 2012

Based on record review, staff interview, and Administrative Policy review during the standard recertification survey, it was determined that the facility did not conduct the minimum required background checks on new employees. 10 NYCRR 483.13 (c)(1) states that facilities may not employ individuals with a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property. Specifically, the State nurse aid registry check and a NY State Department of Education Office of the Professions check was not conducted for 1 of 1 licensed new employees. This resulted in no actual harm with the potential for minimal harm. This is evidenced as follows.

The personnel file for employee #1, a registered nurse (RN) hired on 10/27/2012, was reviewed on 12/12/2012. This record review revealed that the facility had not conducted a State nurse aide registry check for this employee. Further, this review revealed that a professional licensure verification check through the NY State Department of Education Office of the Professions was not conducted for this employee.

The Confidential Secretary and Administrator stated in an interview conducted on 12/12/2012 at 11:30 AM that a State nurse aide registry check and a NY State Department of Education Office of the Professions check was not conducted for employee #1 as she was a re-hire attesting that she left employment on 11/15/2011 and was re-hired on 10/27/2012.

The policies " CHRC Procedures " and " Procedure for the Monitoring of Newly Hired Employees " were reviewed on 12/12/2012. " CHRC Procedures " is silent on the requirement for conducting a State nurse aide registry check for new employees. " Procedure for the Monitoring of Newly Hired Employees " exempts from monitoring, employees who hold a verifiable professional licensure or certification.

10 NYCRR 483.13(c) (1)

F165 483.10(f)(1): VOICE GRIEVANCES WITHOUT REPRISAL

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

A resident has a right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished.

Citation date: December 18, 2012

Based on medical record review and interviews during an abbreviated survey (Case#NY00121213) it was determined that the facility did not ensure for one ( Resident #2) of three residents reviewed that the resident's grievances were adequately addressed with a resolution, and did not apprise the resident of the progress of the grievance. Specifically, the resident had concerns with regards to the administration of her medications and the practice of mixing insulins. The resident's brother contacted the Administrator and Director of Nursing (DON) regarding the concerns asking for a meeting. The facility did not respond to the resident's brother or the resident, regarding these concerns. This resulted in no harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidence by the following:

Resident #2:
The resident was admitted to the facility with diagnoses of diabetes, seizure disorder and osteoporosis. The resident was assessed to have no cognitive impairment.

The facility policy titled "Grievance Process" dated 9/98, documented its purpose was: to provide a method for residents and/or designated representatives and staff members to communicate recommendations/grievances or complaints to Administration; to assure that recommendations or complaints are reviewed and resolved in a timely manner; to assure a response is made to the individual initiating the recommendation/complaint/grievance as soon as possible but no later than 21 days after receipt.

The facility forms titled grievances on 10/18/12, were reviewed for the previous three months, which did not reveal a grievance for Resident #2.

A medication error report dated 8/17/12 documented at 9:30 pm that Resident #2
received an injection of Lantus and Humalog Insulin combined (which is contraindicated).

A Sanofi Company documents safety warnings for Lantus Insulin " Do NOT dilute or mix Lantus with any other insulin or solution. It will not work as intended and you may lose blood sugar control, which could be serious".
During an interview on 10/18/12 at approximately 1:00 pm the DON stated there was no additional documentation regarding the medication error report dated 8/17/12.

During an interview on 10/18/12 at approximately 2:15 pm Resident #2 stated her brother takes care of everything for her, he is her Power of Attorney (POA) and Health Care Proxy (HCP). Resident #2 stated she was very upset with a recent medication errors. Resident #2 stated she has asked her brother to speak to the facility on her behalf. Resident #2 stated she doesn't feel they have done anything to correct the situation.

During an interview on 10/18/12 at approximately 4:00 pm, the Administrator and the DON stated they were unaware of any grievance for Resident #2.

A facility letter received on 10/22/12 which was dated 10/19/12, addressed to Resident #2's brother, documented the facility Administrator was in receipt of correspondence dated 9/11/12 from the brother regarding concerns about the resident's medications. The letter documented the brother's letter had been misplaced and overlooked. Additionally, the letter documented the facility could not discuss medical information with the brother.

Documentation from the post office on 10/22/12 revealed a registered letter from the brother of Resident #2, was received at the facility on 9/14/12.

10 NYCRR 415.3(c)(1)(i)

K62 NFPA 101: SPRINKLER SYSTEM MAINTENANCE

Scope: Widespread

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Citation date: December 18, 2012

Based on review of inspection records and staff interview during the standard recertification survey, it was determined that the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systemsnone 1998 edition section 1-11.1 requires that maintenance shall be performed to keep the system equipment operable or to make repairs. Specifically, 4 of the last 4 required quarterly sprinkler system test reports stated " Unable to complete the fire pump test. Fire pump for standpipe is not in service. Hand Hoses dated 11/2006 need hydro testing. Some hoses are not properly racked in various areas on all floors. " This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The sprinkler system test reports for the 4 quarters of 2012 were reviewed on 12/13/2012. These reports all stated " Unable to complete the fire pump test. Fire pump for standpipe is not in service. Hand Hoses dated 11/2006 need hydro testing. Some hoses are not properly racked in various areas on all floors. "

The Director of Environmental Services stated in an interview conducted on 12/13/2012 at 9:00 AM that he cannot speak as to why the hand hoses have not been hydro tested and the hand hose racking is not completed. Further, he stated that repairing the standpipe component of the sprinkler system is an ongoing project and some attempts at repair were conducted during August 2012.

2000 NFPA 101 19.7.5; 1998 NFPA 25 -11.1; 1997 NFPA 101 7-7.5; 1995 NFPA 25 1-11.1; 10 NYCRR 415.29, 711.2(a) (1)

K25 NFPA 101: SMOKE PARTITION CONSTRUCTION

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Citation date: December 18, 2012

THIS IS A REPEAT DEFICIENCY FROM THE DECEMBER 2011 RECERTIFICATION SURVEY. Based on observation and staff interview during the standard recertification survey, it was determined that the facility did not maintain the integrity of 1 of 1 smoke barriers observed. NFPA 101 Life Safety Codenone 2000 edition section 8.3.2 requires that smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling. Specifically, the smoke barrier wall on the 2 High-rise Unit was not continuous above the ceiling. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced with the following three examples.

The smoke barrier wall on the 2 High-rise Unit was inspected on 12/13/2102 at 11:45 AM. This smoke barrier had a 2-foot by 10-inch duct and a conduit wire that were not sealed between the fixture and the smoke barrier wall, and a 6-inch by 4-inch space was found in the smoke barrier wall above the metal support beam and the underside of the floor/ceiling assembly.

The Director of Environmental Services stated in an interview conducted on 12/13/2012 at 11:45 AM that he made the same observations of the 2 High-rise Unit smoke barrier wall as the survey observations.

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

K52 NFPA 101: TESTING OF FIRE ALARM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 14, 2013

A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4

Citation date: December 18, 2012

Based on record review and interview during the standard recertification survey, it was determined that the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72, National Fire Alarm Code none 1999 edition section 7-3.2 requires annual tests for duct smoke detectors. Specifically, 11 of 27 duct smoke detectors (DSD) were not tested annually. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The fire alarm testing records from February 2011 through August 2012 were reviewed on 12/13/2012. The 2 ELEVATOR LOBBY DSD, 2 SOUTH HALL BY FIRE DOORS DSD, 3 ELEVATOR LOBBY, 3 SOUTH HALL BY FIRE DOORS DSD, 4 HALLWAY ELEVATOR DSD, 4 HALLWAY SOUTH DSD, 5 ELEVATOR LOBBY DSD, and 5 HALLWAY SOUTH DSD were not tested within the 18 month period prior to February 2011; the 1 NORTH WING FAN RM 9109 DSD was not tested within the 15 month period prior to May 2012; and the 1D UNIT HALL BY FIRE DOORS DSD and the 1 SHAKER PLACE HALL BY NURSE STATION DSD were last tested during February 2011.

The Director of Environmental Services stated in an interview conducted on 12/13/2012 at 9:00 AM that he had expected the contracted testing company to test the fire alarm system initiating devices according to the adopted standard once per year.

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

K160 NFPA 101: EXISTING ELEVATOR REQUIREMENTS

Scope: Widespread

Severity: Potential for no more than Minimal Harm

Corrected Date: February 14, 2013

All existing elevators, having a travel distance of 25 ft. or more above or below the level that best serves the needs of emergency personnel for fire fighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. 19.5.3, 9.4.3.2

Citation date: December 18, 2012

The following requirement of Life Safety Code has been previously waived. The results of the current survey and review of the facility's previously submitted justification reaffirm that adequate safeguards remain in place to protect residents, staff and visitors. Correction would pose an undue hardship. The continued waiver of the following item is recommended contingent upon satisfactory progress towards construction of the replacement facility.
Please indicate your request for renewal or provide a plan of correction in the space provided on this form.

All existing elevators, having a travel distance of 25 ft. or more above or below the level that best serves the needs of emergency personnel for fire-fighting purposes, conform to Firefighter's Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.

2000 NFPA 101 19.5.3, 9.4.3.2; CFR 483.70 (a); ASME/ANSI A17.3; NYCRR 711.2 (a) (1); 1997 NFPA 101 13-5.3, 7-4.5

\i Two of 2 elevators in the facility having a travel distance of greater than 25 feet, do not conform to Firefighter's Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. These requirements include firefighters service phase I key recall and smoke detector automatic recall, firefighters service phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.

The policy of the facility is to assign a staff person to lock down the elevator on the first floor upon fire alarm activation.

K144 NFPA 101: GENERATORS INSPECTED/TESTED

Scope: Widespread

Severity: Potential for no more than Minimal Harm

Corrected Date: February 14, 2013

Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1.

Citation date: December 18, 2012

Based on interview and record review during the standard recertification survey, it was determined that the facility did not maintain emergency generator testing records (testing records) according to adopted regulations. NFPA 99 Standard for Health Care Facilitiesnone 1999 edition section 3-4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systemsnone 1999 edition section 6-3.4 requires that the facility maintain operational testing records that include the date, exercising period, performance, identification of the servicing personnel, and identification of any unsatisfactory condition with the appropriate corrective action and re-testing. Specifically, 2 of the last 12 months of tests were not recorded. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The facility testing records for 2012 were reviewed on 12/13/2012. No records were provided for the months of 02/2012 and 03/2012.

The Director of Environmental Services stated in an interview conducted on 12/13/2012 at 9:00 AM that the emergency generator was tested during 02/2012 and 03/2012 but he cannot find the records for these tests.

1999 NFPA 99 3.4.4.1, 1999 NFPA 110 6-3.4, 6-4.2; 1996 NFPA 99 3.4.4.1; 1996 NFPA 110 6-3.4, 6-4.2; 10 NYCRR 415.29(a)(2), 711.2, 713-1.19(h)