Schoellkopf Health Center

Based on record review and staff interview, the facility did not ensure compliance with requirements of State law regarding advance directives. One (Resident #115) of one resident reviewed for Hospice services revealed the facility did not activate the Health Care Proxy (HCP) prior to allowing the Health Care Agent to make medical decisions for the resident. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #115 has diagnoses of dementia and low back pain. Review of the significant change Minimum Data Set (MDS) dated 10/20/11 revealed the resident has severe cognitive impairment, rarely/never understands, and is rarely understood.

Review of 30/60 Day Medical Evaluation dated 10/31/11 revealed on Hospice for decline in overall condition, decreased vocalization and responsiveness to communication (does not respond to questions), and is on Tylenol and Lidoderm (medicated adhesive patch used to treat back pain).

Review of Physician's orders signed on 10/31/11 included orders for the following:

- Extra Strength Tylenol 500 milligrams (mg), 2 tablets by mouth (po) three times daily for pain management at 9:00 AM, 1:00 PM and 9:00 PM;
- Tylenol 325 mg 2 tablets by mouth every 4 hours for pain (do not exceed 4,000 mg of APAP/24 hours from all sources of scheduled/prn products);
- Morphine Sulfate (controlled substance used to treat pain) liquid 5 mg every 2 hours as needed sublingual (beneath the tongue) for pain/dyspnea,
- Lidoderm 5 patch apply topically to lower back in the morning, leave on 12 hours and remove at night.

Review of the Medication Administration Record (MAR) dated 12/1/11 to 12/31/11 revealed the resident has received the scheduled Tylenol and Lidoderm. Unscheduled/ as needed pain medication was not documented as given.

During an interview on 12/20/11 at 3:20 PM, the Registered Nurse (RN) Hospice Nurse revealed the resident is not on scheduled Morphine because the Health Care Agent (HCA) does not want the resident to receive the medication.

Interview on 12/20/11 at approximately 3:25 PM, with the Physician revealed she believed the previous physician activated the resident's health care proxy.

Interview on 12/21/11 at approximately 8:00 AM with the RN Nurse Manager revealed the resident has not received Morphine because the HCA does not want the resident to receive the medication. Although the Health Care Proxy has not been activated, decisions about the resident's care are based both on the resident's wishes and family information.

Additional interview with the resident's Physician on 12/21/11 at approximately 9:00 AM revealed the resident's Health Care Proxy requires activation because the resident has lacked capacity to make decisions regarding his care for quite some time.

415.3(e)(2)(iii)

Based on observation, record review, and staff and Health Care Agent (HCA) interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #115) of one resident reviewed for Hospice services had an issue with the lack of an effective pain medication regimen. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #115 has diagnoses of dementia and low back pain. Review of the significant change Minimum Data Set (MDS) dated 10/20/11 revealed the resident has severe cognitive impairment, rarely/never understands, and is rarely understood.

Review of a 30/60 Day Medical Evaluation dated 10/31/11 revealed the resident was on Hospice due to decline in overall condition, decreased vocalization and responsiveness to communication (does not respond to questions); and receives Lidoderm (local anesthestic (pain reliever) patch) and Tylenol for back pain.

Review of Physician's orders signed on 10/31/11 revealed the following orders:

- Extra Strength Tylenol 500 milligrams (mg), 2 tablets by mouth (po) three times daily for pain management at 9:00 AM, 1:00 PM and 9:00 PM;
- Tylenol 325 mg 2 tablets by mouth every 4 hours for pain (do not exceed 4,000 mg of APAP/24 hours from all sources of scheduled/prn products);
- Morphine Sulfate (narcotic pain medication) liquid 5 mg every 2 hours as needed sublingual (beneath the tongue) for pain/dyspnea (difficulty breathing),
- Lidoderm 5 % (percent) patch, apply topically to lower back daily in the morning, leave on 12 hours and remove at HS (bedtime).

Review of the current Plan of Care revealed the resident was identified at risk for pain or discomfort due to a history of gouty arthritis, a decrease in ambulation and increased weakness. Planned approaches include the following:

- provide routine medications as ordered,
- monitor results and keep MD informed,
- administer prn (as needed) medications as ordered,
- monitor effect of medication,
- use alternative methods to relieve discomfort such as a change in position.

Additional review of the Plan of Care revealed the resident entered into Hospice care on 10/20/11 with a goal to keep the resident comfortable for the remainder of his stay in the facility. Planned approaches included:

- confering with Hospice regarding pain medication,
- monitoring the resident for signs or symptoms of pain with the assistance of Hospice,
- providing a Hospice Nurse, Social Work, and a Spiritual Advisor on a routine basis,
- keep the family informed,
- listen to family concerns.

Observation on 12/20/11 at 6:41 AM revealed a certified nurse aide (CNA) was providing morning care and had finished washing the resident (who was lying naked in bed) and she began to dress the resident. The CNA repositioned the resident to the middle of the bed with a draw sheet and the resident resident yelled out "Ow, Ow" twice. The resident was observed to tense his whole body and both his arms had tremors immediately after the motion. Once the motion was done, the resident was immediately calm. The CNA began placing a T-shirt on the resident, who stated "Ow" as the CNA raised his left arm. The CNA proceeded to pull the T-shirt over the resident's head and the resident stated he was sore and his "head hurts more and more". The CNA began to dress the resident in a sweatshirt and the resident stated "Ow". The CNA rolled the resident on his right side by pushing on the resident's left hip and the resident stated "Ow, Ow, Ow". The CNA then rolled the resident to his left and the resident continued to say "Ow, Ow, Ow". The resident again stated everything hurts. This process lasted approximately 10 minutes.

Observation on 12/20/11 at 8:10 AM revealed the Registered Nurse (RN) Nurse Manager performed a skin assessment of the resident's pressure ulcers and the resident was lying on his right side with the sacral (area between the tailbone on the right and left buttocks) dressing off. The RN Nurse Manager measured the pressure ulcers and the resident stated "Ow" several times when the pressure ulcers were touched. The Licensed Practical Nurse (LPN) Treatment Nurse completed the dressing change and the resident calmed down at intervals when he was not being touched.

The RN Nurse Manager then instructed the CNA to clean the resident, who was having a bowel movement. quickly because the resident was uncomfortable.

Observation on 12/20/11 at 10:00 AM revealed the LPN Treatment Nurse administered Tylenol 500 mg 2 tablets and the Lidoderm patch to the resident.

Review of the Medication Administration Record (MAR) for 12/1/11 to 12/31/11 revealed the resident had last received pain medication, Tylenol 500 mg 2 tablets at 9:00 PM on 12/19/11. Additional review of the 12/11 MAR revealed the resident received the scheduled Tylenol and Lidoderm for pain management. No unscheduled, (as needed) pain medication and/or treatments were documented as given.

Interview on 12/20/11 at 10:30 AM with the resident's Health Care Agent (HCA) revealed she is concerned about the resident's back pain and wants the facility staff to keep him comfortable without sedating him. The HCA stated the Hospice nurse recommended a low dose of Morphine; however, she was concerned about the sedating effect because the resident has always liked to be active and watching his surroundings. The HCA stated that in the past she has asked the Hospice Nurse and the Nurse Manager to give him something stronger than Tylenol and not as sedating as Morphine to treat his back pain.

Interview with the RN Nurse Manager on 12/20/11 at approximately 3:00 PM, revealed she contacted the physician and obtained an order for Motrin (nonsteroidal anti-inflammatory medication) based on the resident's discomfort during the skin assessment/treatment.

During an interview on 12/20/11 at approximately 3:15 PM, the LPN Medication Nurse stated the CNA did not report anything to her regarding the resident and she was unaware that the resident experienced pain during the dressing changes that morning. The LPN stated that the resident is known to have pain on movement and once he is back in position, he is comfortable.

Interview with the Hospice RN on 12/20/11 at 3:20 PM, revealed she received her information about the resident's pain control from the nursing home staff. The RN stated she has not observed the resident in pain and the resident has denied that he is in pain. She has not visualized the resident with hands on care and she knows the HCA does not want him to have a lot of pain medication. Prior to this, no one ever informed her that the resident had occasional pain/discomfort with hands on care in the morning.

Interview with the Physician on 12/20/11 at 3:24 PM, revealed it was her understanding that the Health Care Agent did not want the resident to have additional pain medication. The Physician stated she was not aware that the resident was uncomfortable during dressing changes in the morning. The Physician also stated that the scheduled pain medication at 9:00 AM, 1:00 PM and 9:00 PM was probably not managing the resident's pain well and they will trial a change in the pain medication regimen.

415.12

none

Based on observation and staff interview during a Life Safety Code survey, a hazardous area door was held open by a device that was not arranged to automatically close the door upon activation of the required manual fire alarm system, local smoke detectors and/or the automatic sprinkler system. This affected one (Second Floor) of four resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the Second Floor on 12/19/11 at approximately 7:54 AM revealed that the door to the storage room located near resident room #2016 was in a fully open position and that no staff were in the area around the room. Also at this time observation revealed that the door was being held open by an approximate six foot tall by five foot long by two foot wide clean linen cart. Further observation at this time revealed that this room contained the following:

- one six foot tall by five foot long by two foot wide clean linen cart full of cloth bed pads, sheets and towels,
- 10 cardboard cases of disposable briefs
- 10, 18 count plastic packages of disposable briefs.

Continued observation at this time revealed the storage room door had a sign attached to it that read as follows "ATTENTION ALL STAFF LINEN RM DOOR IS TO BE CLOSED AT ALL TIMES WHEN STAFF IS FINISHED GETTING LINEN OFF CART".

Observation on the Second Floor on 12/20/11 at approximately 1:57 PM revealed that the door to the storage room located near resident room #2016 was in a fully open position. Also at this time observation revealed that the door was being held open by an approximate six foot tall by five foot long by two foot wide clean linen cart. Further observation at this time revealed that this room contained the following:

- one six foot tall by five foot long by two foot wide clean linen cart full of cloth bed pads, sheets and towels,
- 9 cardboard cases of disposable briefs
- 8, 18 count plastic packages of disposable briefs.

Continued observation at this time revealed the storage room door had a sign attached to it that read as follows "ATTENTION ALL STAFF LINEN RM DOOR IS TO BE CLOSED AT ALL TIMES WHEN STAFF IS FINISHED GETTING LINEN OFF CART".

Interview with the Administrator on 12/21/11 at approximately 11:25 AM revealed that staff had been previously in-serviced on not blocking doors.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA: 19.2.2.2.6

Based on observation and staff interview during a Life Safety Code survey, a means of egress was not continuously maintained free of all obstructions or impediments to full and instant use in case of fire or other emergency. This affected one (Ground Floor) of four resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observations on the Ground Floor on 12/16/11 at approximately 8:42 AM and at 11:02 AM revealed the following was stored in the Equipment Room corridor:

- one approximately four foot tall by four foot long by four foot wide wheelchair,
- two mechanical lifts,
- one chair,
- two approximately three and one half foot tall by three foot long by two foot wide soiled linen/trash receptacles,
- one broken shower chair,
- two electrical wheelchairs,
- one three foot high by five foot long by two foot long shower bed/table,
- one six foot long by four foot wide sheet of tag board,
- one four foot tall by three foot long by three foot wide mechanical lift,
- two four foot long by two foot wide metal ceiling tiles,
- one three foot long by two foot wide framed window,
- one three foot long by two foot wide piece of metal frame work,
- one four foot tall by two foot wide easel,
- one three foot in diameter circular wooden table top,
- one four foot long by three foot wide table with a glass top,
- one walker
- one plastic wet floor sign.

Further observations at these times revealed that these items were stored on both sides of the corridor and that one area of the corridor was constricted to a clear width of approximately two feet.

Interview with the Director of Facilities Management on 12/16/11 at approximately 11:02 AM revealed that he was not aware that items were currently being stored in the Equipment room corridor. ne
Observation on the Ground Floor on 12/16/11 revealed all of the items that were observed to be stored in the Equipment room corridor at 8:42 AM and 11:02 AM were still stored in the corridor at approximately 3:15 PM. Also at this time observation revealed that these items were still stored on both sides of the corridor and that one area of the corridor was still constricted to a clear width of approximately two feet.

Interview with the Director of Facilities Management on 12/21/11 at approximately 11:15 AM revealed that he had previously removed items that had been stored in this corridor on at least two occasions.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 2000 NFPA 101: 7.1.10, 7.1.10.1, 7.1.10.2, 7.1.10.2.1

Based on observation and staff interview during a Life Safety Code survey, hazardous area doors would not self-close and latch into their frames and/or were not designed to resist the passage of smoke. This affected two (Second Floor, Third Floor) of four resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observations on the Third Floor on 12/16/11 at approximately 9:00 AM and 10:11 AM revealed that the door to the Tub/Storage room would not self-close and latch into its frame. Also at these times observations revealed that there was an approximate one inch gap between the door and its frame thus compromising the doors ability to resist the passage of smoke. Further observation at these times revealed that this room contained the following:

- one approximately six foot tall by four foot long by two foot wide blue plastic linen cart full of cloth bed pads,
- one approximately 20 gallon plastic bag full of towels,
- one approximately 20 gallon plastic bag full of garbage
- the shower room located within this room also contained at least four cardboard boxes full of holiday decorations.

Continued observations during these times revealed that this room was located near resident room #3000.

Interview with the Director of Facilities Management on 12/16/11 at approximately 10:11 AM revealed that he was not aware that the door would not self-close and latch into its frame.

2. Observation on the Third Floor on 12/16/11 at approximately 9:05 AM revealed the door to the storage room near resident room #3016 would not self-close and latch into its frame. Also at this time observation revealed that this room contained the following:

- one six foot tall by five foot long by two foot wide clean linen cart full of cloth bed pads, sheets and towels,
- one wooden shelving unit containing floor pads,
- four plastic packages of disposable briefs, pillows and two cardboard boxes of medical supplies.

3. Observations on the Second Floor on 12/16/11 at approximately 9:15 AM and 10:23 AM revealed the door to the Tub/Storage room would not self-close and latch into its frame. Also at these times observations revealed that there was an approximate one inch gap between the door and its frame thus compromising the doors ability to resist the passage of smoke. Further observations at these times revealed that this room contained the following:

- one approximately six foot tall by four foot long by two foot wide blue plastic linen cart full of cloth bed pads,
- at least 13 cardboard boxes full of holiday decorations,
- one shower bed/table
- three commodes.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 2000 NFPA 101: 19.3.2.1

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 11/14/08, 11/5/09 and 1/13/11.

Based on observation, record review and staff interview, the facility's two elevators did not meet the requirements for existing elevators serving four or more stories. The deficient practice was the lack of Firefighter's Service equipment for the elevators. This was widespread with no actual harm with potential for minimal harm.

The findings are:

1. The nursing home building was a four-story building comprised of a ground floor and three floors that contained resident sleeping rooms. There are two elevators that service the facility. It was observed on 12/19/11 at approximately 12:16 PM and confirmed during an interview with the Director of Facilities Management at this time, that neither of the elevators was equipped with Firefighter's Service equipment that would allow controlled use of the elevators under fire emergency conditions.

The facility requested an initial waiver from complying with this Life Safety Code requirement following the survey dated 6/30/05. An approval letter dated 3/25/09 from the Centers for Medicare & Medicaid Services was received by the New York State Department of Health Western Regional Office in Buffalo New York on 3/30/09 and revealed the following: "The New York State Department of Health had recommended to the Centers for Medicare & Medicaid Services (CMS) that your request for a time limited waiver of Life Safety Code requirements, specifically for NFPA 101 Life Safety Code Standard: K160 be approved.

Based on documentation submitted, CMS accepted the recommendation and therefore granted a two year time limited waiver for the NFPA 101 Life Safety Code Standard: K160. The waiver was approved for the period covering 12/13/07 through 12/13/09." On 11/27/09 the New York State Department of Health Western Regional Office in Buffalo, New York received a letter from the facility dated 11/27/09 requesting an extension of the time limited waiver that expired 12/13/09 for K160. This letter also revealed that the facility's Administrator had spoken to a representative of the Centers for Medicaid and Medicare Services (CMS) about this extension and that this CMS representative had agreed to grant the facility an extension until 8/13/13 to have Firefighters' Service equipment installed in the facility's elevators, provided the local and state departments were also in agreement, and that the facility had a reasonable explanation for requesting an extension.

Interview with the Administrator on 12/19/11 at approximately 2:26 PM revealed that the facility was still requesting an extension of the waiver for K160 until 8/13/13. As of 12/23/11 the New York State Department of Health Western Regional Office in Buffalo, New York had not received documentation from all parties involved in the possible extension of the waiver for K160 until 8/13/13.

Adequate safeguards remain in place to protect residents, staff and visitors.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.5.3, 9-4.5