Cuba Memorial Hospital Inc SNF

Based on observation, record review and staff interview, the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Three (Residents #3, 6, 7) of five residents observed for bed side rail use had issues involving spaces within the side rail that could pose a potential entrapment hazard. In addition, the facility did not assure safety assessments were in compliance with safe measurements per policy. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #7 has diagnoses including dementia with behaviors, depression, and hypertension (high blood pressure). Review of a Minimum Data Set (MDS) dated 3/30/10 revealed the resident is independent in cognitive skills for daily decision making, has no short or long term memory problems, is understood and understands. Further review of the MDS revealed the resident has impaired vision, has bed rails (side rails), and requires extensive assist of 2 for bed mobility.

Review of an Environmental Safety Side Rail Assessment tool dated 3/26/10 revealed the instructions are to score the resident's risk factors and a score of 24 or more = high risk for injury. The resident scored a 21.

Review of a Physical Therapy Screening dated 5/21/10 revealed Nursing Recommendations for 1/4 side rails both upper.

Review of the Side Rail Consent form dated 8/27/09 revealed the resident's representative signed for side rail use.

Review of an Interdisciplinary Plan of Care with a Nursing review date of 4/14/10 revealed the resident has upper side rails for bed mobility and safety per request.

Observation on 6/2/10 at approximately 7:00 PM during the Unit 3 initial tour with the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) revealed Resident #7 was lying in bed with both side rails (SR) in the up position on her bed. The SRs were noted to have 2 vertical bars, creating 3 openings. The LPN RCC was requested to measure the three openings in the SR. The 3 open spaces in both the right and left upper 1/4 SR each measured 7 and inches in width x 7 and 3/4 inches in height. Further observation on 6/2/10 at 9:50 PM revealed the LPN RCC had taped sheets over both of the SRs to enclose the open areas for overnight because the maintenance men were already gone for the night.

Interview on 6/3/10 at 8:15 AM with the LPN RCC revealed the maintenance department came through very early this morning and replaced the SR or beds. Further interview with the LPN RCC and the LPN Treatment Nurse on 6/3/10 at approximately 10:10 AM revealed Resident #7's SRs had been in the same room/location since "around Christmas (2009).

Review of the facility policy entitled Maintenance Side Rail Safety Assessment with the revision date of 2/10 revealed the Assessment Tool shall be completed on each bed with side rails twice a year by an employee of the maintenance department. The Maintenance staff designee is instructed to complete documentation on the Assessment form and will include Zones 1 through 7. Zone 1 is the measurement within the rail and is less than 4 and 3/4 inches. Also attached to the policy are diagrams that show the location of each Zone to measure and drawings of potential entrapment areas on the side rails and/or bed.

Review of a Maintenance Side Rail Safety Assessment dated 1/18/10 revealed a form that references Zones 1 through 7 from the policy. The Maintenance designee had checked Zones 1 through 7 were compliant. The attached sheet titled Maintenance Side Rail Safety Assessment Schedule dated 1/18/10 revealed a list of all of the beds in the facility. The bed for Resident #7 was listed as "N/A" which according to the schedule indicated the bed did not have a side rail.

On 6/3/10 at 1:20 PM the interview with the Maintenance Technician (MT) revealed the MT stated the beds with the 7 and 3/4 inches openings were "changed out this morning at 6:00 AM". The MT stated he performed and signed the Maintenance Side Rail Safety Assessment Schedule dated 1/18/10. The MT stated he did not know why he wrote "N/A" for Resident #7's bed because the bed had the same side rails all along. The MT stated he did not measure the openings on the side rails when he did the Maintenance Side Rail Safety assessment because he (the MT) "assumed since the beds were already in use when he (MT) started working at the facility approximately 3 years ago that the beds were already in compliance".

Interview with the Director of Nursing (DON) on 6/3/10 at 2:40 PM revealed the DON stated he wrote the Side Rail Safety: Environmental Safety Side Rail Assessment and Maintenance Side Rail Safety Assessment policy in 2006 and added the diagrams, and assessment tools to ensure the side rails were safe and in compliance to eliminate potential entrapment hazards. The DON stated the MT did not do what he was supposed to do.

Interview with the Administrator on 6/3/10 at 5:00 PM revealed the Administrator stated the MT did not follow the policy and procedure.

2. Resident #6 has diagnoses of osteoarthritis (OA), failure to thrive, generalized weakness and dementia. Review of a Minimum Data Set (MDS) dated 3/10/2010 revealed the resident has been at the facility since 4/2/08, is independent in cognitive skills for daily decision making, has no short or long term memory problems, is understood and understands.

Review of Environmental Safety Side Rail Assessments dated 10/5/09 and 3/1010 revealed the resident scored 20. A score of 24 or more = high risk for injury. Review of a Physical Therapy Screening dated 12/16/09 and 3/9/10 under Nursing Recommendations revealed recommendations for 1/4 side rails both upper.

Review of the resident's Plan of Care and a Side Rail Consent dated 7/4/08 revealed that the resident has 2 1/4 side rails.

During the initial tour of Unit 3 on 6/2/2010 at approximately 6:15 PM, Resident #6 was observed in bed with (2) 1/4 side rails in the up position on the side of her hospital bed. The side rails had three 7 3/4" x 7 3/4" openings, as measured by the RCC at 7:15 PM. This space was large enough for the resident to get her head or the upper or lower extremity through the opening and cause entrapment.

Intermittent observation of the resident in bed on 6/2/10 from 6:15 PM to 8:00 PM revealed the resident was able to use the SR to help position herself in the bed.

Review of a Maintenance Side Rail Assessment dated 1/18/10, revealed that the Maintenance Technician who inspected Resident #6's side rails recorded that the side rails were in compliance.

On 6/3/10 at 1:20 PM the interview with the Maintenance Technician (MT) revealed the MT stated the beds with the 7 and 3/4 inches openings were "changed out this morning at 6:00 AM". The MT stated he performed and signed the Maintenance Side Rail Safety Assessment Schedule dated 1/18/10. The MT stated he did not know why he wrote in compliance for Resident #6's bed because the bed had the same side rails all along. The MT stated he did not measure the openings on the side rails when he did the Maintenance Side Rail Safety assessment because he (the MT) "assumed since the beds were already in use when he (MT) started working at the facility approximately 3 years ago that the beds were already in compliance".

Interview with the RCC on 6/3/2010 at 1:30 PM revealed Resident #6 has been in the same hospital bed with the same side rails since 4/2/08.

Review of a Maintenance Side Rail Safety Assessment policy last revised 2/10 included the following:

- the Maintenance Side Rail Safety Assessment tool shall be completed twice yearly on each bed with side rails.
- if an area is found out of compliance on the Maintenance Side Rail Safety Assessment, the bed will be removed from operation until it is made compliant.

3. Resident #3 has diagnoses including Alzheimer's disease and depression. Review of a Minimum Data Set (MDS) dated 5/19/10 identified the resident has moderately impaired cognitive skills for daily decision making. Review of a Comprehensive Care Plan (CCP) dated 3/10 identified the resident as having poor impulse control, anxiety and agitation.

Review of an Environmental Safety Side Rail Assessment dated 2/17/10 revealed the resident scored 21. A score of 24 or more = high risk for injury.

Review of a Physical Therapy Screening dated 2/16/10 and 5/10/10 revealed the resident requires 1 assist for bed mobility and "bed rails per family's request".

Review of a Side Rail Consent form dated 1/17/10 revealed consent for the use of both upper side rails.

Intermittent observation of the resident's room on 6/2/10 from 7:20 PM to approximately 10:30 PM revealed that the resident's bed with two 1/4 side rails in the up position was unoccupied. The side rails were noted to have three 7 3/4 inch (") x 7 3/4" openings, as measured by the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) at this time.

Interview with the LPN RCC on 6/2/10 at 7:25 PM revealed that the resident can be restless at times whether in a chair or in bed.

Review of a policy and procedure entitled "Environmental Safety Side Rail Assessment and Maintenance Side Rail Safety Record Assessment", revised 2/10, included a procedure to assess that the side rail openings are less than 4 3/4 inches.

When interviewed on 6/2/10 at 9:30 PM, the RCC said that the side rails have been in use since 1/17/10 and that she did not realize that the side rails had openings measuring 7 3/4" x 7 3/4". The RCC further stated that the side rails did not meet safety standards according to the Maintenance Side Rail Safety Record Assessment.

Review of a Side Rail Assessment Schedule completed by the Maintenance Technician on 1/18/10 revealed a space n/a (non applicable) was documented next to Resident #3's room. Interview with the Maintenance Technician on 6/3/10 at 1:20 PM revealed that (n/a) indicated no side rails.

415.12(h)(1)

415.19 INFECTION CONTROL

The facility shall establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection.

These requirements are not met.

STATE ONLY

Based on record review and staff interview, the facility did not establish and maintain an infection control program designed to provide safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Two (Employees #8, 9) of eleven Employee Health files reviewed for employee immunization revealed evidence that employees were not provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations and were not immunized.

During an interview with the Employee Infection Control staff on 6/4/10 at 10:45 AM it was learned that at the beginning of the flu season, approximately mid-October, employees receive notification of the availability of the influenza vaccine with informational inserts. The Employee Infection Control staff further explained that she was responsible for the documentation of the immunization status of each employee, but she did not place any documentation in the files for these two individuals.

415.19

1. Resident #7 has diagnoses including dementia with behaviors, depression, and hypertension (high blood pressure). Review of a Minimum Data Set (MDS) dated 3/30/10 revealed the resident is independent in cognitive skills for daily decision making, has no short or long term memory problems, is understood and understands.

Review of a facility policy entitled Transcription with a revision date of 2/10 revealed all physicians' orders will be noted with the signature, date and time by the Registered Nurse (RN) and/or Licensed Practical Nurse (LPN). All orders will have a 24 hour check by an RN/LPN with signature, date and time placed at the end of the orders noting that the orders have been checked by the nurse.

Review of the Medication Administration Record (MAR) book on 6/3/10 at 9:45 AM revealed instructions for the LPN's that included check the MD orders with the MAR for transcription accuracy and check for the correct dose when administering medications.

Review of Physician's Orders dated 5/20/10 revealed the Physician ordered the current dose of Seroquel 25 milligrams (mg) tablet (12.5 mg) by mouth every morning to be increased to Seroquel 25 mg one tablet every morning.

Review of a MAR dated 5/10 revealed the Seroquel 25 mg tablet every morning was discontinued on 5/20/10 and the new order for the increase to Seroquel 25 mg one tablet in the morning was documented. Review of the MAR dated 6/10 revealed the old order for Seroquel 25 mg tab every morning was crossed out and handwritten was the directions to "see below". The handwritten entry at the bottom of the MAR read, "Seroquel 25 mg tab in the morning". The nurses documented with their initials the Seroquel 25 mg tablet was administered on 6/1/10, 6/2/10, and 6/3/10.

Interview with the Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) and the LPN Medication Nurse on 6/3/10 at 9:45 AM revealed the LPN Medication Nurse was asked to check the blister pack of Seroquel 25 mg for the resident. The directions on the blister pack read to give the resident Seroquel 25 mg one tablet in the morning which matched the physician's orders dated 5/20/10 but did not match the MAR dated 6/10. The LPN Medication Nurse stated he documented and administered the morning dose of Seroquel 25 mg one tablet to the resident and also stated he did not clarify the discrepancies between the Physician Orders and the blister pack with the MAR but should have. The LPN RCC stated someone wrote the same dosage on the 6/10 MAR which was wrong. The LPN RCC stated the discrepancy of the dosage on the MAR should have been clarified before the resident was administered the Seroquel for the last three days.

415.11(c)(3)(i)

Based on record review and staff interview during a Life Safety Code survey, the main (350 kW (kilowatt) emergency generator did not engage load within a ten-second period of time. This affected two (Unit Two, Unit Three) of two resident units and the First and Ground floors. This was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Review of the facility's emergency generator testing records on 6/3/10 at approximately 11:50 AM revealed the 350 kilowatt (kw) emergency generator failed to engage within a ten-second time period during Load tests during the following months:

- 3/10 (12 seconds),
- 2/10 (12 seconds),
- 11/09 (12 seconds),
- 10/09 (15 seconds),
- 9/09 (15 seconds),

Further review of the facility's testing records at this same time revealed the Normal operating range for the Emergency Generator to transfer Load is 6 seconds. Per NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities 1999 Edition, the emergency generator shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. An interview with the facility Maintenance Director on 6/4/10 at approximately 10:49 AM revealed there are no operating problems with the Emergency Generator and he was unaware of the time period exceeding 10 seconds.

1999 NFPA 99; 3-4.1.1.8
1999 NFPA 110; 3-4.1
10 NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation and staff interview during a Life Safety survey, the smoke/fire alarm system was not properly maintained. Issues include the facility's lack of prompt response to trouble signals that registered at the main fire panel and two remote annunciator panels. This affected three (First, Second, Third Floors) of three resident use floors and the basement. This was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 6/2/10 at approximately 8:15 PM revealed the remote annunciator panel located at the Second Floor nurse's station had three indicator lights illuminated at the panel that showed: a trouble message at the panel, the panel was silenced and the panel was offline. A trouble message was flashing at the display screen that read "Network Communication Trouble". An interview with the Administrator on 6/2/10 at approximately 9:00 PM revealed the Main fire panel is in the Maintenance Shop at the ground floor and at this time we do not have access to the room.

An interview with the facility Director of Maintenance on 6/3/10 at approximately 10:15 AM revealed the annunciator panels are reading normal. There is a trouble signal that shows up when the weather gets bad that may be attributed to a grounding problem. The system is externally supervised by an alarm monitoring company. If the system was to go offline the monitoring company would detect the lack of a signal and call the facility to see if they are in need of help.

Observation on 6/3/10 at approximately 2:42 PM revealed the remote annunciator panel located at the Second Floor nurse's station once again, had three indicator lights illuminated at the panel that showed: a trouble message at the panel, the panel was silenced and the panel was offline. A trouble message was flashing at the display screen that read "Network Communication Trouble".

Observation of the Main Fire Panel at the Maintenance shop on 6/3/10 at approximately 2:46 PM revealed three indicator lights illuminated at the panel that showed: a trouble message at the panel and the panel was silenced. A message at the display screen read (0-Alarm) (3-Trouble) (0-Supervisor). The Main panel was online. An interview with Maintenance staff at this same time revealed that there is a second remote annunciator panel located at the First Floor urgent care center. This area is located in the section of the building that houses the hospital. It is noted that the hospital is not included in the survey involving the Skilled Nursing Facility, however since this annunciator panel is a component of the fire alarm system that protects the Skilled Nursing Facility, it has been included in this review.

Observation on 6/3/10 at approximately 2:55 PM revealed the remote annunciator panel located at the Urgent Care Center First Floor, had three indicator lights illuminated at the panel that showed: a trouble message at the panel, the panel was silenced and the panel was offline. A trouble message was flashing at the display screen that read "Network Communication Trouble". An interview with a member of the Maintenance staff at this time revealed the audible alarms that sound at all panels have to be physically silenced. Based on an interview with the urgent care center staff behind the counter of the Urgent Care Center confirmed the panel had been beeping and they were unsure of who silenced the panel.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 7-6.1.4
2000 NFPA 101: 9.6.1.4
1999 NFPA 72: 3-8.1

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 8/12/09.

Based on observation during a Life Safety Code survey, smoke barrier doors were obstructed from closing and were not properly closed. This affected one (Second Floor) of three 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 6/2/10 at approximately 7:15 PM revealed the Smoke barrier doors between the First floor elevator lobby and the Urgent care center were not fully closed. The right leaf of the door assembly had an astragal installed. The left leaf of the door assembly was closed such that the door got stuck on the astragal preventing it from fully closing. The door was again observed in this condition on 6/4/10 at approximately 10:20 AM.

2. Observation on 6/2/10 at approximately 8:01 PM revealed the Second floor single-leaf, smoke barrier door located near the elevator lobby was obstructed from closing by a chair that was next to a table and a second chair. When the door was physically released from the magnetic hold open device the door hit the chair and could not close.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-3.7.6
2000 NFPA 101: 19.3.7.6

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED 8/12/09 and 10/2/08.

Based on observation during a Life Safety Code survey, means of egress were not continuously maintained free of all obstructions. This affected two (Second, Third Floor) of three resident use floors and the Ground Floor. The issue includes passable space limited to less than four feet on the Second and Third Floor and storage in the corridor on the Ground floor. 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 6/2/10 at approximately 6:50 PM revealed the following items stored in the corridor behind the kitchen at the ground floor: a three-foot high by two-foot long box labeled "hp" on a two-wheeled cart, an empty 50-gallon trash can, a wooden pallet with four-cases of computer paper and other various boxes of items stacked approximately six-feet high on top and a pallet jack. Additional observation at this same time revealed that further down this same corridor across from the purchasing department the following items were stored in the corridor: three, four-wheeled carts with various size boxes of items stacked on top; two metal carts with various sized boxes of printer cartridges, a large printer, and three floor standing mobile thermometers.

2. Observation on 6/2/10 at approximately 7:35 PM revealed the corridor between resident rooms #311 - 312 on the Third Floor was obstructed to less than three-feet of passable space due to the storage of two open wheelchairs on one side of the corridor and a sit/stand lift and a gerichair on the opposite side of the corridor.

3. Observation on 6/2/10 at approximately 7:56 PM revealed the corridor between resident rooms #245 - 247 on the Second Floor was obstructed to less than two-feet of passable space due to the storage of five wheelchairs on one side of the corridor and two wheelchairs with residents on the opposite side of the corridor.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 5-1.10
2000 NFPA 101: 7.1.10

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 8/12/09.

Based on observation during a Life Safety Code survey, hazardous areas were not properly protected. This affected the Main Kitchen located on the ground floor and one (Unit Two) of two resident units. Issues include self latching mechanisms lacking on the kitchen doors and a door that did not self latch. This was a pattern with no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 6/2/10 at approximately 6:20 PM revealed two of three corridor doors that open into the Main kitchen lacked latching mechanisms that would automatically engage when the doors close. These doors are equipped with self closing mechanisms and dead bolt locks that have to be physically twisted locked. The doors include the Main Kitchen door and the Dishwasher room door.

2. Observation on 6/2/10 at approximately 7:48 PM revealed the Clean Utility room corridor door closest to resident room #242 on Unit 2 did not positively self latch. The door latched closed only when physically pulled closed.

3. Observation on 6/2/10 at approximately 7:52 PM revealed the Linen Storage room corridor door closest to resident room #244 on Unit 2 did not positively self latch. The door latched closed only when physically pulled closed.

2000 NFPA 101: 19.3.2.1
1997 NFPA 101: 13-3.2.1
10 NYCRR 415.29(a) (2), 711.2(a) (1)

Based on observation during a Life Safety Code survey, oxygen was improperly stored in one of one Main Oxygen storage rooms located in the Therapy Wing on the First Floor. This affected the Therapy Wing on the First Floor. Issues include one unsecured oxygen cylinder stored within this room. 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 6/2/10 at approximately 7:11 PM revealed one unsecured E-sized oxygen cylinder stored unsecured, freestanding, on the floor in the Main Oxygen Storage room located in the Therapy Wing on the First Floor.

10 NYCRR 415.29(a), 711.2(a)(1)
1997 NFPA 101: 13-3.2.4
2000 NFPA 101; 19.3.2.4
1999 NFPA 99: 4.3.1.1.1

Based on observation during a Life Safety survey, the egress stairwell from the ground floor Therapy corridor was not properly constructed. The issue includes a storage room door constructed underneath the stairs with an access door to the room accessible from within the stairwell. 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 6/2/10 at approximately 7:08 PM revealed the exit stairwell at the end of the Ground Floor Therapy wing corridor has a storage room installed such that the door to this room opens into the stairwell. At the time of this observation the door was observed to be open. The contents of this room include but were not limited to walkers, crutches and padding. Per NFPA 101 2000 edition: There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. The noted exception to this code reference states: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 5-1.3.2.2, 5-2.2.5.3
2000 NFPA 101: 7.1.3.2.2, 7.2.2.5.3