Woodbury Center for Health Care

Based on record review and staff and resident interviews during the recertification Quality Indicator Survey (QIS), it was determined that a Comprehensive Care Plan (CCP) was not revised to address safety interventions after a fall with injuries for one of two residents reviewed for accidents. Specifically, Resident #193 had a fall on 3/10/11 and there was no documented evidence that the CCP was revised to reflect updated safety interventions following an incident of a fall with an injury. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During an observation and interview on 3/26/11 at 1:00 PM Resident #193 was noted with an ecchymotic (bruise) area on her left forehead and under both eyes. The resident could not recall what happened and the resident denied any pain. The resident was sitting in her wheel chair (W/C) in her room and there was a chair alarm in place.

A CCP dated 1/5/11 documented diagnoses including Dementia, Psychosis and Depression and that the resident has forgetfulness and short term memory loss. The CCP also documented that the resident is at risk for falls due to psychotropic medication regime and that the resident has bed and W/C sensor alarms in place.

The Minimum Data Set Assessment (MDS) dated 3/18/11 documented a Brief Interview for Mental Status (BIMS) score of 8 ( moderate cognitive impairment). The MDS also documents that there are no behavior symptoms/ no behavior exhibited. The MDS further documented that the resident had one fall with injuries, and no fractures since admission to the facility. The MDS also documented that the resident was assessed and had no pain.

An Accident/ Incident (A/ I) Report dated 3/10/11 documented that the resident was found on the floor in her room lying in front of the W/C near her bed and that the chair alarm was sounding. The A/ I also documented that the resident had a hematoma on her left forehead and pain in her left hand and left knee. There was no new safety interventions documented on the A/I.

A Nurses Note (NN) dated 3/10/11 at 7:15 PM documented that the resident was found on the floor in her room in front of the W/C and that the alarm was sounding. The NN also documented that the resident had a complaint of pain in her left arm. The Physician ordered the resident be transferred to the hospital for an evaluation.

A NN dated 3/10/11 documented that the resident returned to the facility at 11:30 PM from the hospital. An assessment was completed and the resident had an abrasion to the left forehead 4 centimeters (cm) by 2 cm with surrounding ecchymosis. A Neuro Check was completed and Tylenol was administered for pain with effect. The NN further stated that there was ecchymosis under both eyes.

A Certified Nursing Assistant Record dated 3/2011 documented that the resident had bed and chair alarms and 1/2 hour checks were in place. There was no documented updated interventions after the fall 3/10/11.

A review of Physical and Occupational Therapy Notes revealed that there was no documented evidence that an evaluation was completed after the residents fall on 3/10/11.

There is no documented evidence that the facility revised the CCP after the resident had a fall with injuries on 3/10/11 for further safety measures.

An interview was held on 4/1/11 at 10:00 AM with the Director of Nursing Services (DNS) who completed the fall CCP and the A/I. The DNS reviewed the A/I and CCP and stated that there was no documented evidence that the CCP was updated with new interventions after the resident's 3/10/11 fall with injuries. The DNS also stated that she spoke with the unit Charge Nurse who stated to her that she thought that a Dycem mat (a device to prevent slipping out of the chair) was instituted, but the intervention was not documented in the medical record.

An interview was held on 4/1/11 at 11:00 AM with the Occupational Therapist (OT). The OT stated that she reviewed the medical record and that there was no documented evidence the CCP was revised after the resident's fall on 3/10/11 and a Dycem mat was not implemented at that time.

415.11(c)(2)

Based on record review and staff and resident interviews during the Recertification Quality Indicator Survey (QIS), the facility did not ensure that appropriate medically related Social Services were provided for one resident in a total sample of 31 residents reviewed. Specifically, there was no documented evidence that the Social Worker (SW) notified staff about the resident's depression and thoughts of suicide for appropriate intervention. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #95 has diagnoses including Depression.

The Quarterly Minimum Data Set (MDS) Assessment dated 3/17/11 documented that the resident's Brief Interview for Mental Status (BIMS) resulted in a score of 15, which determined that the resident was cognitively intact. The MDS further documented that the resident had the ability to express ideas and wants and could clearly comprehend/understand others with no memory problems. The MDS Resident Mood Interview documented that the resident had thoughts that she would be better off dead, or of hurting herself in some way (D-i) for 2-6 days. The MDS documented that a safety notification was made for the potential of resident self-harm to the responsible staff.

The Comprehensive Care Plan (CCP) for Mood/Psychosocial well being, updated on 3/16/11 documented that during the resident's Mood Interview today, the resident stated that she had been feeling down, depressed and hopeless. The CCP documented that the resident stated that "she had thoughts that she would be better off dead 2-6 days over the past two weeks. . .". The CCP update documented the conclusion that the resident had an overall decrease in the mood severity score and that the current goals and approaches would be continued. There were no new interventions documented.

The Social Services Progress Note dated 3/16/11 documented that the Mood Interview for the Quarterly MDS indicated that the resident had been feeling down, depressed or hopeless. The SW further documented that the resident had been feeling hopeless for one day over the past two weeks. The SW documented that the resident had stated that she had been feeling tired and had trouble sleeping for seven to eleven days over the past two weeks. The SW documented that resident stated she would be better off dead. The SW documented that the resident had made the statement related to her age (101) and that the resident denied having any thought of hurting herself. The SW documented that Nursing was informed and that the SW would continue to follow up with the resident.

The Nursing Progress Notes were reviewed from 3/16/11 through 3/17/11. There was no documented evidence related to the resident's mood interview or depressed behaviors during that MDS period 3/11/11-3/17/11. There was no documented evidence that any additional, immediate behavior assessments were completed or any immediate behavior monitoring was instituted to rule out self harm.

The Medical Record was reviewed from 3/16/11-3/17/11 and there was no documented evidence that the Physician or the Psychiatrist had been notified of the resident's mood interview. There were no behavior tracking notes documented in the medical record for that period.

The Director of Nursing Services (DNS) was interviewed on 3/31/11 at 10:00 AM. The DNS stated that the Psychiatrist should have been called immediately and that the resident should have been put on behavior monitoring.

On 3/31/11 at 10:30 AM the SW was interviewed. The SW stated that she had notified nursing, but could not recall who the nurse was. The SW stated that she had completed an extensive interview with the resident on 3/16/11 and had determined that the resident would not have hurt herself. The SW stated that the resident had a long history of depression and that the Psychiatrist had followed up with the resident 3/7/11. The SW stated that she did regular follow ups with the resident. The SW further stated that she would have expected the Nursing Department to monitor the resident's behavior following the interview on 3/16/11 and to notify the Physician or Psychiatrist, according to facility policy.

The Registered Nurse/Manager (RN) was interviewed on 3/31/11 at 10:50 AM. The RN had not recalled being notified regarding the resident's mood interview 3/16/11. The RN explained that it could have been any nursing staff on any shift including any supervisor. The RN further stated that the Psychiatrist would have been notified by her immediately, she would have personally interviewed the resident, and the resident would have been put on behavior monitoring. In addition, the RN stated that it would have been documented on the 24-hour report. (The 24 hour report was no longer available for that date). The RN stated that is the facility policy.

The facility undated Policy titled Psychiatric Consultations documented that a Psychiatric Consult is necessary for any resident who expressed suicidal thoughts, ... and will be so ordered by the attending physician... When the resident answers yes to thoughts of self-harm during mood interview with social work, nursing is immediately notified and will call for a psychiatric consultation.

415.5(g)(1)(i-xv)

Physical Plant Violations- State Only

1) NYCRR 713-1.19 Electrical Requirements

(g) Nurse's calling system (1) General. In general patient areas, each room shall be served by at least one calling station and each bed shall be provided with a call button. Two call buttons serving adjacent beds may be served by one calling station. Calls shall register with the floor staff and shall activate a visible signal in the corridor at the patients' door, in the clean workroom, in the soiled workroom, and in the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at the corridor intersections. In rooms containing two or more calling stations, and remain lighted as long as the voice circuit is operating.

These requirements are not MET as evidenced by:

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain the resident call system as required in 713-1.19(g)(1) in that corridor intersection lights were not provided for multiple corridors on three of three nursing units.

This resulted in no actual harm with potential for minimal harm.

The findings are:

On 03/28/11 between 9:00am- 1:00pm, it was noted that the facility did not maintain the resident call system as required in that corridor intersection lights were not provided for multiple corridor intersections on the A, B and C nursing units.

In an interview on the same day at approximately 10:15am the Director of Environmental Services stated that he was not aware of the corridor intersection lights not being installed since he started working at the facility and that they would be installed.

T he following requirement of the Life Safety Code has been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed.

Please indicate if the facility wants the waiver continued, or provide a plan of correction.

Two exit stairwells from the basement do not terminate directly at a public way or at an exit discharge. The stairwells discharge to a first floor corridor.

42 CFR 483.70(a), NFPA 101 - 2000: 18.2.4.1, 18.2.4.2, 19.2.4.1, 19.2.4.2,
10NYCRR 415.29(a), 711.2(a)(1)