Woodmere Rehab & Health Care Center, Inc

Based on record review and staff interviews during the recertification survey the facility did not ensure that all resident's drug regimens were free from unnecessary drugs. This was evident for 2 of 22 residents reviewed for Psychoactive mediations in a total of 30 reviewed. Specifically, 1) Resident #19 received Benadryl (an Antihistamine) every night for greater than 3 months without adequate monitoring and; 2) Resident #24 received Seroquel (Antipsychotic medication) between 7/2009 and 12/2010 without attempted dose reductions (approximately 17 months). 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 including Right Calf Stasis Ulcer, Alzheimer's Disease and Dementia with Behavioral Problems.

The Minimum Data Set (MDS) Assessments dated 6/22/10 through 12/5/10 documented that the resident was moderately impaired with cognitive skills for daily decision making and had both long and short-term memory problems. The MDSs also documented that the resident presented with a Stasis Ulcer.

A Progress note dated 9/20/10 completed by the resident's Attending Physician documented that the resident had a Chronic Leg Ulcer. The Physician documented that the ulcer had reopened secondary to "patient scratching". The note documented a plan to initiate Benadryl at Hour Of Sleep (HS).

A Physician's Order Form dated 9/20/10 documented an order for Benadryl 25 milligrams (mg) by mouth at bedtime for a diagnoses of Pruritic (itchy) Lesion.

A subsequent Progress note dated 10/11/10 completed by the resident's Attending Physician documented that the resident's right leg had an open wound with areas of excoriation with blood-tinged exudate. The Physician documented a plan to increase Benadryl.

A Physician's Order Form dated 10/11/10 documented an order for Benadryl 50 milligrams (mg) by mouth at bedtime for a diagnoses of Pruritic Lesion.

There was no documented evidence in the resident's medical record between 10/12/10 and 2/7/11 of monitoring related to the resident's response to the treatment of Benadryl daily for a Pruritic Lesion.

A Physician's Progress note dated 1/10/11 documented that the resident was reported to have been "picking at wound...heavy bleeding". The plan related to the behavior was to have a Psychiatric evaluation for "self mutilating behavior". There was no documentation of an evaluation of the effectiveness of the Benadryl medication in the progress note.

An interview was conducted on 2/8/11 at 8:30 AM with the Certified Nursing Assistant (CNA) responsible for Resident #19. The CNA stated that she had been working with the resident for over six months. The CNA stated that the resident scratched at her leg wound daily and removed the bandage daily and the behavior has never improved in the past six months.

An interview was conducted on 2/8/11 at 9:35 AM with the Registered Nurse (RN) Charge Nurse. The RN stated that she was aware of the resident's scratching behavior and that the Physician Assistant (PA) was responsible for wound care recommendations. The RN stated that she was unable to locate a Comprehensive Care Plan for the Scratching behavior and that there should have been one developed.

An interview was conducted on 2/8/11 at 11:45 AM with Resident #19's Attending Physician. The Physician stated that they should have documented that the Benadryl had been effective to stop the resident from scratching at the wound. The Physician stated that the PA should have documented in the Wound Care Notes about the effectiveness of the medication.

An interview was conducted on 2/8/11 at 12:25 PM with the PA responsible for the wound care for Resident #19. The PA stated that he forgot that the Benadryl had been ordered for the resident. The PA stated that he had not noticed any obvious changes in the resident with the use of the Benadryl. The PA stated that if there was no improvement with the use of the medication within two weeks of use, then the Benadryl should have been reassessed.

2) Resident #24 was admitted to the facility with diagnoses including Schizophrenia and Hypotension.

The MDS Assessments dated 10/26/09 through 12/10/10 documented that the resident was moderately impaired with cognitive skills for daily decision making. The MDSs also documented that the resident did not present with any behavioral symptoms.

The Physician's Orders dated 7/28/09 through 12/27/10 documented an order for Seroquel (Antipsychotic medication) 200 mg by mouth in the AM and 400 mg by mouth at bedtime for a diagnoses of Schizophrenia.

There were four documented Psychiatric evaluations dated 11/27/09 through 9/20/10 that documented that Resident #24 presented with a diagnosis of Dementia due to Alzheimer's Disease with Delirium and History of Schizophrenia. The Psychiatrist documented that the resident had not presented with Psychosis or Agitation. Each evaluation documented to continue the Seroquel at 200 mg in the AM and 400 mg at bedtime. Each assessment documented that a dosage reduction had not been attempted in the past 4-6 months. There was no documented evidence on the evaluations documenting a rationale for no attempt at a dose reduction for the resident's Antipsychotic medication.

A Psychiatric evaluation dated 12/28/10 documented that the resident was not Psychotic or Agitated and that a dose reduction will be attempted.

A Physician's Order dated 12/28/10 documented that the bedtime dose of Seroquel was reduced from 400 mg to 200 mg.

A facility Policy titled Psychoactive medications dated 3/2008 was reviewed. The Policy documented that gradual dose reductions shall be attempted unless clinically contraindicated. The Policy did not document who would be responsible to implement and document if and when a dose reduction should or should not be attempted.

An interview was conducted on 2/8/11 at 1:35 PM with the Licensed Practical Nurse (LPN) responsible for Resident #24. The LPN stated that she had worked with the resident for over one year and that the resident had never presented with any behavioral symptoms. The LPN stated that she was aware that the resident had a dose reduction in 12/2010 and that there had not been any changes to the resident's behavior since the medication change.

An interview was conducted on 2/8/11 at 1:40 PM with the RN Charge Nurse. The RN stated that the resident had never had any behavioral problems. The RN stated that the Psychiatrist writes their own orders.

An interview was conducted on 2/8/11 at 2:12 PM with the Psychiatrist responsible for Resident #24. The Psychiatrist stated that for chronic disorders of Dementia with Behavioral Disturbances, a reduction of the dosage of medications used for Psychosis should be attempted every 3 to 6 months. The Psychiatrist stated that the rule to attempt reduction is not applicable to Schizophrenics. The Psychiatrist stated that he should have documented the rationale why he did not attempt a dose reduction sooner for Resident #24.

415.12 (1) (i)

Based on observation, staff interviews, and record review during the recertification survey, the facility did not ensure that proper infection control techniques were implemented during a wound care treatment to prevent the development and transmission of infection. This was evident for one of one resident (Resident #2) observed for a wound treatment in a total sample of 30 residents reviewed. Specifically, the Registered Nurse (RN) Treatment Nurse was observed, after completing a treatment, to touch a gastrostomy feeding pump and chart a treatment, without washing her hands. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #2 has diagnoses which include Anoxic Cerebral Injury and Stage IV Pressure Ulcer.

The Minimum Data Set (MDS) Assessment 3.0 dated 11/08/10 documented that Resident #2 had short and long term memory problems and was severely impaired in decision making.

Physician Orders dated 1/22/11 documented to apply Santyl Ointment (a chemical debriding agent) daily and as needed after cleanse with Normal Saline, cover with dry protective dressing (packed with wet to moist gauze), and apply Bacitracin with Zinc Ointment to the Sacral periwound (around the wound) twice a day.

During an observation of wound care for Resident #2 on 2/4/11 at 9:30 AM, the RN was observed to wash her hands, don clean gloves, cleanse the wound with Normal Saline soaked gauze, throw the gauze into a garbage bag, remove her gloves and wash her hands. The RN was observed to don clean gloves, apply Santyl ointment with an applicator stick, place the stick into the garbage bag, and pack the wound with Normal Saline soaked gauze. The RN then applied Bacitracin with Zinc Ointment with an applicator stick to the periwound and placed the applicator stick into the garbage bag. The RN covered the wound with gauze, opened a package which contained a Dry Protective Dressing and covered the gauze. The RN then removed her gloves, took the garbage bag off the table and placed it into the garbage can in the room. The RN was observed to touch Resident #2's Gastrostomy Feeding Pump, and then chart the treatment in the Treatment Administration Record without having washed her hands first.

The Treatment Nurse RN was immediately interviewed. The RN stated that she should have washed her hands after removing her gloves and before touching anything in the resident's room or before charting the treatment.

The RN Inservice Coordinator was interviewed on 2/08/11 at 8:45 AM. The RN stated that the Treatment Nurse should have washed her hands after removing her gloves.

A facility policy and procedure dated 10/08 titled Handwashing/Infection Control documented to wash hands after removing disposable gloves.

415.19(b)(4)

Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public.

Housekeeping

The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, shall be clean. The facility shall be maintained in good repair including, but not limited to buildings, utilities, fixed equipment, resident care equipment and furnishings.

This requirement is not met as evidenced by:

Based on observation and staff interview during the recertification survey, the facility did not maintain the grab bar in a common area, and a common shower room in good repair in 1 of 2 nursing home buildings.

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

The findings are:

During environmental rounds on 2/4/11 between 8:30am and 11:00am the following was observed in one of two nursing home buildings (specifically, the South building):

1. The grab bar in the 3rd floor bathroom was observed with a flaking and scuffed plastic surface, and portions of the floor corners (grout) of the shower stall in the 2nd floor shower/tub room were observed with brown and black stains. In addition, the lower portion of the door frame to the room was observed with a rusty surface.

In interviews at approximately 8:45am and 9:00am, the Administrator stated that the identified issues would be addressed by the maintenance department.

415.29 (j) (1)

Based on record review and staff interviews during the recertification survey the facility did not ensure that irregularities in medication duration and indications for use were identified and reported to the facility. This was evident for 1 of 22 residents reviewed for Psychoactive medications in a total of 30 sampled residents. Specifically, Resident #19 received Benadryl (an Antihistamine commonly used for allergy symptoms and known to have a Central Nervous System adverse reaction that includes Seizures as per Nursing Drug Handbook 2010, Lippincott, Williams & Wilkins, Ambler PA.) every night for greater than 3 months and there was no documented evidence that the Pharmacist identified or notified the facility of the potential for adverse reactions related to the Benadryl and/or the required monitoring necessary for the continued use of the Benadryl. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings is:

Resident #19 has diagnoses including Right Calf Stasis Ulcer, Alzheimer's Disease and Seizure Disorder.

A Progress note dated 9/20/10 completed by the resident's Attending Physician documented that the resident had a chronic leg ulcer. The Physician documented that the ulcer had reopened secondary to "patient scratching". The note documented a plan to initiate Benadryl at Hour Of Sleep (HS).

A Physician's Order Form dated 9/20/10 documented an order for Benadryl 25 milligrams (mg) by mouth at bedtime for a diagnoses of Pruritic (itchy) Lesion.

A subsequent Progress note dated 10/11/10 completed by the resident's Attending Physician documented that the resident's right leg had an open wound with areas of excoriation with blood-tinged exudate. The Physician documented a plan to increase the dosage of Benadryl.

A Physician's Order Form dated 10/11/10 documented an order for Benadryl 50 milligrams (mg) by mouth at bedtime for a diagnoses of Pruritic Lesion.

There was no documented evidence in the resident's medical record between 10/12/10 and 2/7/11 of monitoring related to the resident's response to the treatment of Benadryl daily for a Pruritic Lesion.

Forms titled Medication Regimen Review documented that a Pharmacist had reviewed the resident's medication on 10/25/10, 11/18/10, 12/17/10 and 1/13/11. The section on the form titled Other Notes was blank.

An interview was conducted on 2/8/11 at 10:00 AM with the Pharmacist that completed the medication regimen reviews for Resident #19. The Pharmacist stated that within a month of starting a resident on a medication to prevent itching that the effectiveness should have been evaluated by the facility staff. The Pharmacist stated that if the Benadryl was not effective within one month then they would normally recommend a Dermatology consultation for other causes of the symptoms. The Pharmacist stated that they could not recall if they had made any recommendations regarding the Benadryl medication used for Resident #19 between 10/26/10 and 2/7/11.

An interview was conducted on 2/8/11 at 11:15 AM with the Assistant Director of Nursing (ADNS). The ADNS stated that the the Pharmacy Review reports are kept in the nursing office and that if there were recommendations for a resident it would be on the reports for those specific dates. The ADNS stated that there were no Pharmacist recommendations for Resident #19 documented on any of the Pharmacy reports on file between 9/24/10 through 1/13/11.

415.18(c)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that all residents received appropriate medical supervision for changes in resident's medical status. This was evident for one of thirty sampled residents reviewed. Specifically, Resident #16 was seen by an Ear, Nose and Throat (ENT) Specialist for Cerumen (wax) build up and the recommendations for treatment were not implemented by the Attending Physician. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident # 16 has diagnoses that include Dementia and Diabetes Mellitus.

The Minimum Data Set (MDS) Assessment dated 11/20/10 documented the resident's cognition as severely impaired.

A Physician's Order dated 12/8/10 documented an order for the resident to be seen for an ENT Consult.

On 1/13/11 an ENT Consult dated 12/8/10 was completed for Resident #16. The consult documented that the resident was evaluated for Cerumen build up. The recommendations documented by the ENT Physician were Debrox (softens and removes ear wax) ear drops, 5 drops in each ear twice a day for 10 days. The consult was signed by the Attending Physician.

On 2/8/11 at 10:30 AM the Registered Nurse (RN) Charge Nurse was interviewed. The RN reviewed the medical record and stated that there was no order for the Debrox. The RN further stated that the physician had signed the consult indicating that it had been reviewed. The RN also stated that if the recommendations made by the ENT were not being followed the attending physician should have documented in the medical record why they were not be followed.

The medical record was reviewed and there was no documented evidence that the Debrox had been ordered for Resident #16.

The Medication Administration Record (MAR) dated 1/10/11 through 2/9/11 was reviewed. The was no Debrox documented on the MAR.

On 2/8/11 at 11:20 AM the Physician was interviewed. The physician stated that they are usually notified by nursing after a consult had been completed. Nursing will convey the recommendations that were made by the specialist. The Physician further stated that she would have expected to have an order for the Debrox and, "perhaps it was somewhere in the medical record."

415.15 (b) (1) (i) (ii)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that services provided by an outside agency were provided in a timely manner. This was evident for one of one resident reviewed for a Pacemaker in a total of thirty sampled residents. Specifically, Resident #16 did not have a Pacemaker check documented as being completed as prescribed by the Physician. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #16 has diagnoses that include Dementia and Diabetes Mellitus.

A Consultation dated 9/29/10 documented that the Pacemaker check had been completed. The Consultation also documented to recheck in three months.

There was no documented evidence in the medical record that a Pacemaker check had been completed for December 2010.

On 2/8/11 at 11:00 AM the Registered Nurse (RN) Charge Nurse was interviewed. The RN was unable to locate the Pacemaker check for December 2010.

On 2/8/11 at 11:20 AM the Physician was interviewed. The Physician stated that they would have expected the Pacemaker check to be completed every three months as ordered.

On 2/8/11 at 2:00 PM the Director of Nursing Services (DNS) was interviewed. The DNS stated that the coordination of all Pacemaker checks for the facility takes place with a vascular physician. The DNS was unable to state why the Pacemaker check for Resident #16 was not completed.

The Policy and Procedure (P/P) dated 4/05 and titled Pacemaker: Cardiac was reviewed. The P/P documented to ensure that Pacemaker checks are conducted and reported monthly. The P/P also documented to notify the Physician of any communication from the Pacemaker testing company.

On 2/8/11 at 2:15 PM the Pacemaker company responsible to provide services to the facility was contacted. The medical records department was unable to address if Resident #16 had any pacemaker checks after 9/29/10.

415.26 (e) (i-iv)

Based on observation and staff interview, the facility did not provide a Type 1 Essential Electrical System (EES) in that wiring from the critical branch (C) and life safety branch (LS) was noted in the same emergency power panel boards. This was noted in the North building boiler room.

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

The findings are:

On 2/4/11 at approximately 1:30pm during the re-certification survey, wiring from both the critical branch and life safety branch was noted in the same emergency power panel boards. It was noted that the facility has a ventilator unit on the 2nd floor of the North building requiring the facility to have a Type 1 EES. Circuits serving both the " #10 Call System 3rd Floor " (C) and the " #26 & 28 Fire Alarm Power " (LS) were noted in emergency power panel board " EM Panel #1 " and circuits serving both the " Nurse Call Bell System " (C) and " Fire Alarm, Fire Door Holder and Exit Sign Lights " (LS) were noted in emergency power panel board " 3B- E.E.P. " in the North building boiler room.

In an interview on 2/4/11 at approximately 1:30pm, the Director of Maintenance stated that the facility will request a waiver.

711.2(a)(1), NFPA 70: Article 517, Article 700

Based on observations and staff interviews during the recertification survey, the facility did not ensure that the building containing the healthcare occupancy was not compromised by the placement of non-fire resistance rated combustible items/structures less than 10-feet from unprotected windows or door openings.

This resulted in no actual harm but has the potential for minimal harm.

The findings are:

During life safety inspections on 2/4/11 between 8:30am and 11:00am, it was observed that a compactor/dumpster was located at approximately 3 feet of unprotected window openings.

In interview at approximately 9:30am, the Administrator acknowledged the issue with the storage of the non-fire rated combustible item within ten feet of unprotected window openings and stated that it would be addressed.

NYCRR 711.2(a)
10 NYCRR 415.29

Based on observations and staff interviews during the recertification survey, the facility did not ensure that the building containing the healthcare occupancy was not compromised by the placement of non-fire resistance rated combustible items/structures less than 10-feet from unprotected windows or door openings.

This resulted in no actual harm but has the potential for minimal harm.

The findings are:

During life safety inspections on 2/4/11 between 8:30am and 11:00am, it was observed that two storage containers were located at approximately 3 feet of unprotected window openings.
In interview at approximately 11:00am, the Administrator acknowledged the issue with the storage of the non-fire rated combustible items within ten feet of unprotected window openings and stated that it would be addressed.

NYCRR 711.2(a)
10 NYCRR 415.29

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

The following waiver applies to building 0202.

The center stairwell discharges to the first floor lobby and the lobby is not separated from the remainders of the building with one-hour construction.

2000 NFPA 101;19.3.1
NYCRR 711.2

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

The following waiver applies to building 0102.

There are vending machines in the first floor service area corridor.

2000 NFPA 101 ; 1 9 .2.2.1
NYCRR 711.2(a)(1):

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

The following waiver applies to building 0202.

Basement corridors are not provided with two conforming exits.

2000 NFPA 101: 1 9. 2.4.1
NYCRR 711.2(e)(i)

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

The following waiver applies to building 0202.

Travel distance was exceeded to conforming exits on the 2nd and 3rd floor.

2000 NFPA 101 ; 1 9. 2.6.2 .2
NYCRR 711.2(a)(1):