Van Duyn Center for Rehabilitation and Nursing

Deficiency Details, Complaint Survey, April 18, 2011

PFI: 0650
Regional Office: Central New York Regional Office

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F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: May 21, 2011

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Citation date: April 18, 2011

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY00099625), it was determined for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" medical orders, the facility failed to have a system in place to conduct an appropriate and thorough resident assessment to determine the level of supervision required by the resident to maintain his health and safety. Specifically, the facility failed to ensure that Resident #1's health and safety needs were considered prior to allowing him to leave the facility with an out on pass (OOP) medical order. The facility failed to ensure a care plan was developed to address this disabled resident's needs while he would be OOP. The resident subsequently required emergency medical care and hospitalization for multiple serious medical problems after the facility discharged the resident AMA. This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders.
Findings include:

THIS IS A REPEAT DEFICIENCY FROM SURVEYS OF MAY 29, 2009 AND DECEMBER 14, 2010.

The Immediate Jeopardy situation was removed on April 18, 2011, based on the following corrective actions taken by the facility:
- OOP orders for all residents were discontinued;
- a revised OOP assessment and care plan was developed;
- implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges;
- implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident;
- supervisory review of the results of each revised RN OOP assessment;
- supervisory notification of the Medical Director, who (alone) would provide a resident OOP order;
- all staff were in-serviced on the new policies and procedures;
- the resident council was notified of the revised OOP procedures; and
- facility administrative staff monitored all staff to ensure compliance with the new policies and procedures.

*******************************************************
1) Resident #1 was admitted to the facility on February 22, 2011 after treatment for a multi-drug resistant urinary tract infection (UTI) with sepsis (systemic infection). The resident had diagnoses including quadriplegia (paralysis of all extremities), seizure disorder, bipolar disorder, depression, and asthma.

The facility Out on Pass (OOP) Policy, dated June 2009, documents:
- upon admission to the facility, the social worker will meet with the resident and/or designated representative and review the OOP policy, including "the responsibility of the facility to assess and to assure the safety of the resident while out on pass;"
- the interdisciplinary OOP care plan will include the ADL (activities of daily living) needs of the resident and how they will be met while out on pass, and education of the resident /escort about their responsibilities while out on pass; and
- when a resident is ready to leave the facility, the charge nurse will review the care plan to determine that all necessary interventions as identified on the care plan have been addressed with the resident/responsible escort.

The facility Discharge Against Medical Advice (AMA) Policy, dated June 2009, documents:
- a resident who wishes to leave the facility against the advice of the administration, attending physician, and interdisciplinary team will be considered a "self-discharge" AMA;
- documentation in nurses' notes and social work progress notes will reflect the circumstances surrounding the resident's decision to discharge AMA, and outline the information provided to the resident to assist in the decision making process; and
- a physician order will be obtained for "Discharge AMA."

The facility Pre Admission Evaluation, dated February 22, 2011, documented the resident no longer needed rehabilitation therapy, and was to be transferred from another facility to receive long term care. The evaluation documented the resident's family had a wheelchair van to use when the resident went OOP.

The resident's admission physician's orders, dated February 23, 2011, included, "Psych (psychology/psychiatry) consultation for diagnosis of bipolar (disorder)."

The admission Minimum Data Set (MDS) assessment, dated March 1, 2011, documented the resident had normal cognitive ability; had the behavior of rejecting evaluation or care that is necessary to achieve the resident's goals for health and well-being; was non-ambulatory; was totally dependent upon staff for all ADLs; had functional limitation in range of motion of upper and lower extremities on both sides, that interfered with daily functions or placed the resident at risk of injury; had an indwelling urinary catheter; was always incontinent of bowel; had a seizure disorder; had difficulty breathing when lying flat; was at risk of developing pressure ulcers; had 2 Stage II pressure ulcers when admitted to the facility; and received antidepressant and antipsychotic medications.

A registered nurse (RN) Unit Manager progress note, dated March 1, 2011, documented the resident had been asking to go OOP, and was told he did not yet have an OOP physician's order. The resident told his certified nurse aide (CNA) he was leaving the facility, and "did not care" that there was no OOP order. Later that day, the resident left the facility with family members. Facility staff telephoned the resident, who said he "had the OK to leave," and was told he did not. The note documented the RN then obtained a verbal OOP order from the resident's attending physician.

The Out on Pass Risk Assessment, dated March 1, 2011, documented the resident planned to leave the facility with a responsible person who was able to meet the resident's ADL care needs as identified in the CCP (comprehensive care plan). The interdisciplinary team decision was, "Resident safe for OOP with responsible party. Resident has own wheelchair van for transportation."

The resident's CCP, dated March 2, 2011, included the following problems:
- new admission to facility, with difficulty adjusting to placement related to new surroundings, and diagnoses of depression and bipolar disorder. Placement expected to be long term;
- long term Foley catheter for urinary retention, with interventions including use of a leg bag for urine collection when out of bed;
- bipolar disorder, with interventions including medications per physician order and psych consultation PRN (as needed);
- total dependence for ADLs; and
- out on pass with a responsible person (time parameter not specified). Goal for the resident to benefit from the out on pass experience with no ill effects. Interventions included:
a) completion of Out on Pass Log by resident/responsible party including signatures of resident/responsible party and time of departure and return;
b) resident's individual needs will be addressed in these areas when applicable for mealtime/consumption (blank);
c) education of resident/responsible party of expectations and responsibilities when out on pass; and
d) observe for significant symptoms of change in condition or behavior when resident returns to facility.

A nursing progress note, written by the RN Unit Manager on March 17, 2011, documented the resident wanted to go OOP, but his wheelchair van was not functioning. The resident stated 2 of his friends could lift him into a car, and the RN told him this would not be safe for him.

A social services progress note, dated March 18, 2011, documented the resident questioned why he could not be lifted into a car by his friends. The social worker explained this was not safe because the resident needed a mechanical lift for transfers, and verified this with the Director of Physical Therapy. The resident became upset and stated "if this continues to be an issue, (he) may leave AMA in the future."

Physician's orders, dated March 29, 2011, documented the resident could leave the facility "OOP with responsible party (time parameters not specified);" Psych consultation for diagnosis of bipolar disorder; irrigate Foley catheter with normal saline (salt water) PRN; and transfer by 2 persons using a mechanical lift. Medication orders included Keppra (antiseizure drug) 500 mg twice daily; Zoloft (for treatment of bipolar disorder) 50 mg once daily; Zyprexa 5 mg once daily (for treatment of psychosis); Depakote sprinkles (for treatment of bipolar disorder) 250 mg twice daily; and albuterol inhaler (asthma drug) 1 puff every 4 hours.

A nursing progress note, written by the RN Unit Manager on March 31, 2011, documented the resident said he wanted to go OOP on April 1, 2011. He stated he planned to depart on a public bus, and wanted to stay overnight. The note documented the RN told the resident he had an order for a day pass only.

A progress note, written by the physician on April 1, 2011, documented the resident had a history of bipolar disorder and depression, and "we're still waiting for psychiatric follow-up appointment to be scheduled for the patient."

Nursing progress notes, dated April 2, 2011 at 11:53 AM, documented a CNA asked the nurse to assess the resident for a possible UTI. The note documented the resident's urine was cloudy, and the supervisor would be notified. Later that day, at 12:51 PM, a second nurse's note described the resident's urine as cloudy.

A nursing progress note, dated April 3, 2011 at 10:38 PM, documented the resident's urine continued to have a cloudy appearance. Nursing progress notes between April 2 and April 3, 2011 did not include documentation of physician notification of the change in the appearance of the resident's urine.

A licensed practical nurse (LPN) progress note, dated April 4, 2011 at 11:04 PM, documented the resident "went OOP at approximately 6:30 PM. Has not returned as of 11 PM, unable to reach him by phone. Supervisor notified."

A late entry nursing progress note, written by an RN nursing supervisor at 12:24 PM on April 5, 2011, documented:
- on April 4, 2011 at approximately 10:45 PM, she was notified the resident was due to return at 9:00 PM that evening, and had not returned;
- the OOP log book did not specify the time the resident left the facility, nor the signature of a nurse who co-signed (with the escort) that the resident left the facility;
- staff were unable to contact the resident, family, and friends by telephone;
- staff were asked when the last bus would arrive that evening, and stated, "Close to 12:00 AM;" and
- the last bus arrived at 11:57 PM, and the resident was not on the bus.

A nursing progress note, written by the RN Unit Manager at 5:15 PM on April 5, 2011, documented the resident failed to return from OOP as ordered, and the resident was notified he would not be able to return to the facility "per policy." Adult Protective Services was notified, and the resident was advised to go to a hospital emergency room "to get further medical assistance if needed." The resident's physician was notified and provided an order for discharge AMA.

The facility Accident/Incident Report, signed by the former Assistant Administrator on April 5, 2011, documented the resident had been made aware of the OOP policy, and chose to remain OOP beyond the time authorized. A care plan modification was not needed, and the resident was discharged AMA on April 5, 2011.

The resident's April 2011 medication administration record (MAR), documented the following medications were not administered because the resident was out on pass:
- April 4 at 8:00 PM: Keppra 500 mg, Zoloft 50 mg, Zyprexa 5 mg, and albuterol inhaler;
- April 4 at 10:00 PM: Depakote sprinkles 250 mg;
- April 5 at 8:00 AM: albuterol inhaler;
- April 5 at 10:00 AM: Keppra 500 mg and Depakote sprinkles 250 mg;
- April 5 at 12:00 PM: albuterol inhaler.

An emergency medical service (EMS) report, dated April 5, 2011 at 1:27 PM, documented an ambulance was called that afternoon to evaluate the resident in a private apartment. The Resident told EMS staff he was "kicked out" of the facility. He stated facility staff had advised him to call 911, whereupon an ambulance would take him to the hospital to obtain his medications and bring him back (to the apartment). The report documented the resident was told he needed to find another way to get to the hospital, since the ambulance was to be used for emergency services only.

A second EMS report, dated April 5, 2011 at 3:38 PM, documented the resident called for ambulance transportation to the hospital to evaluate a problem with his urinary catheter. The report documented the resident's blood pressure was 140/102 mm Hg (millimeters of mercury) at 3:45 PM, and the resident began to experience a seizure at that time. EMS staff then administered midazolam (sedative, anti-seizure drug) 5 mg intravenously, and again at 3:52 PM. At 4:05 PM, the resident's blood pressure increased to 199/174 mm Hg. The resident became unresponsive, and required placement of an oral/nasal airway device. Upon arrival at the hospital at 4:14 PM, the resident became "notably hypotensive (low blood pressure)," with a blood pressure of 63/33 mm Hg.

The hospital admission history and physical examination, dated April 5, 2011, documented the resident was admitted to the intensive care unit from the emergency department with diagnoses of hypotension, dehydration, seizure disorder, and urinary tract infection. The report documented the resident's urinalysis was abnormal, with increased protein, glucose, white blood cells (sign of infection), bacteria, and large amounts of blood. The report documented a plan for case management consultation for placement of the resident upon his discharge from the hospital because he was not allowed to return to the facility.

A hospital physician's progress note, dated April 6, 2011, documented the resident stated he was staying with friends on April 4 and 5, 2011, and missed his medications. He stated he was having issues of sludge in his Foley (urinary) catheter, and foul-smelling urine prior to being brought to the emergency department on April 5, 2011. The physician's assessment included seizures due to being off his medication, and sepsis secondary to UTI.

A hospital physician's progress note, dated April 18, 2011, documented that per laboratory report, the resident had a multi-drug resistant UTI.

A surveyor interviewed the current Assistant Administrator at 11:30 AM on April 13, 2011 regarding the facility Discharge Against Medical Advice policy. She was unable to explain why the policy does not include a procedure for staff to follow if a resident fails to return to the facility at the time previously planned, nor a procedure for written information given to residents advising them of the facility AMA discharge policy. When asked about staff responsibility to assist Resident #1 to return to the facility in a timely manner when using public transportation, the Assistant Administrator stated this was left up to the resident because he was alert and oriented.

A surveyor interviewed the RN Unit Manager at 2:00 PM on April 13, 2011. When asked about staff responsibility to verify the resident would have been able to safely return to the facility on a public bus on the evening of April 4, 2011, the RN stated the only facility requirement was for the resident to have an escort. She stated the resident telephoned her at 8:00 AM on April 5, 2011, and told her he was unable to call the facility while he was OOP on April 4, 2011 because his cell phone could not access service. He stated the bus he planned to take back to the facility did not arrive. The RN stated she spoke to the resident later that day, and told him to go to the local hospital to obtain his medications. When asked about the facility policy for AMA discharge, the RN stated the facility will not allow a resident to return in the event of intentional elopement.

A surveyor interviewed the Assistant Director of Nursing (ADON) at 8:40 AM on April 15, 2011. When asked how the resident's needs for ADL assistance, such as transfer, positioning, incontinence care, feeding, skin care, and urinary catheter care would be met by the person who accompanied the resident OOP, the ADON stated nursing staff would review the care planned interventions with the responsible person. After reviewing the resident's CCP, the ADON stated this information was not included. When asked about staff training of the resident's friends/family to assist him to travel to and from the facility on a public bus, the ADON stated the resident's care plan would be changed if he experienced an adverse event while using the bus. When asked for documentation that facility staff trained and assessed responsible persons for their ability to care for the resident while OOP, she stated the resident's medical record contained no documentation of this. When asked about the lack of care planning related to the resident's seizure disorder, she stated this should have been included on the CCP. The ADON stated the facility did not provide medications to residents when they went OOP in the event they were unable to return on time. The ADON stated that prior to April 5, 2011, the resident's medical record contained no documented evidence he was told he would be discharged AMA if he failed to return at the predetermined time.

A surveyor interviewed the resident's physician via telephone at 10:50 AM on April 15, 2011. He stated the resident failed to return from a pass on April 4, 2011, and a nurse telephoned him on April 5, 2011 to request an order to discharge the resident from the facility per policy. He stated he was required to follow facility policies. The physician stated he was aware the resident's family wheelchair van had broken down, and he had no opinion regarding the feasibility of the resident using a public bus for transportation. He stated the resident had the right to make his own decisions. The physician stated he was not informed of the resident's cloudy urine on April 2 and 3, 2011, and had no knowledge about the resident's seizure history.

A surveyor interviewed the Medical Director at 11:50 AM on April 15, 2011 regarding the decision to discharge the resident AMA after he failed to return from pass at a predetermined time on April 4, 2011. The Medical Director stated:
- he had no information about the resident's leaving the facility on March 1, 2011, without an OOP order;
- he did not have enough detail about the resident's use of a public bus rather than the care planned wheelchair van for transportation. "The resident can make his own decisions;"
- training of a person responsible for this quadriplegic resident with a urinary catheter and seizure disorder while OOP was unnecessary due to the length of time the resident was to be out of the facility;
- regarding the resident's behaviors, and diagnoses of depression and bipolar disorder, there was no need to assess the resident's judgment and ability to make decisions for his safety while OOP. "Mental illness does not exempt people from being able to make decisions;" and
- the facility policy does not need to document that a resident who leaves the facility AMA will not be allowed to return. "The resident "discharged himself."

A surveyor interviewed the social worker at 12:45 PM on April 15, 2011. She stated that on April 5, 2011, she called Adult Protective Services staff to notify them the resident was discharged AMA that day, and they were confused about the reason the facility would not allow the resident to return to the facility. The social worker said she told them the resident could not return to the facility because he had a day pass, and stayed overnight. The social worker stated the resident called her on April 5, 2011, and said he was on his way to the hospital because his urinary catheter bag had burst.

In summary, the facility failed to protect the health and safety of this quadriplegic resident with multiple medical problems as:
- the interdisciplinary team failed to assess the resident's ability to remain safe when out on pass;
- the facility failed to assure a care plan was developed and implemented to address the resident's multiple physical and medical problems while he was out on pass and subsequently discharged him AMA whch resulted in the need for emergency medical care and hospitalization for seizures and multi-drug resistant urinary sepsis;
- the facility failed to readmit the resident when he stated he wished to return to the facility from pass; and
- the facility failed to implement safe discharge planning.

10 NYCRR 415.12 (h)(2)

F490 483.75: FACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: May 21, 2011

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: April 18, 2011

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY00099625), it was determined the facility's administration failed to administer the facility in a manner that protects the health and safety of residents. Specifically, for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" medical orders, the facility's administration failed to:
- have a system in place to determine the level of supervision required by Resident #1 to maintain his health and safety when out on pass;
- permit Resident #1 to remain in the facility, and not discharge him from the facility unless the discharge was necessary for the resident's welfare, and the resident's needs could not be met in the facility; and
- inform Resident #1 he would be discharged AMA if he did not return from OOP at a predetermined time.
This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders.
The Immediate Jeopardy situation was removed on April 18, 2011 prior to survey exit based on the following corrective actions taken by the facility:
- OOP orders for all residents were discontinued;
- a revised OOP assessment and care plan was developed;
- implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges;
- implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident;
- supervisory review of the results of each revised RN OOP assessment;
- supervisory notification of the Medical Director, who (alone) would provide a resident OOP order;
- all staff were in-serviced on the new policies and procedures;
- the resident council was notified of the revised OOP procedures; and
- facility administrative staff monitored all staff to ensure compliance with the new policies and procedures.

Findings include:

F201 - Resident's right to remain in the facility - The administrator failed to to readmit the resident when he wished to return to the facility after going out on pass.

F284 - Post discharge plan of care - The administrator failed to ensure the resident was discharged with an appropriate discharge plan, and failed to assist the resident and his family to access appropriate placement and medical care upon discharge.

F323 - Accidents - The Administrator failed to have a system in place to conduct an appropriate and thorough resident assessment to determine the level of supervision required to maintain the resident's health and safety when out on pass with untrained individuals.

The Administrator was interviewed at 1:03 PM on April 15, 2011 about the facility's decision to discharge Resident #1 AMA after he did not return from pass at a predetermined time. She stated it was her understanding that the resident knew the meaning of the Discharge AMA policy, and he was aware he would not be allowed to return to the facility if he remained away from the facility overnight.

10NYCRR 415.26(a)

F201 483.12(a)(2): REASONS FOR TRANSFER/DISCHARGE OF RESIDENT

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: May 21, 2011

The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or The facility ceases to operate.

Citation date: April 18, 2011

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY00099625), it was determined for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" medical orders, the facility did not permit the resident to remain in the facility, and not discharge the resident from the facility unless the discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility. Specifically, the facility discharged Resident #1 AMA (against medical advice) , and the facility refused to readmit him when he wished to return to the facility. Subsequently, the resident required emergency medical care and this lead to an acute hospitalization and admission the hospital intensive care unit. This resulted in Immediate Jeopardy and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders.
Findings include:

The Immediate Jeopardy situation was removed on April 18, 2011 prior to survey exit, based on the following corrective actions taken by the facility:
- OOP (out on pass) orders for all residents were discontinued;
- a revised OOP assessment and care plan was developed;
- implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges;
- implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident;
- supervisory review of the results of each revised RN OOP assessment;
- supervisory notification of the Medical Director, who (alone) would provide a resident OOP order;
- all staff were in-serviced on the new policies and procedures;
- the resident council was notified of the revised OOP procedures; and
- facility administrative staff monitored all staff to ensure compliance with the new policies and procedures.

*******************************************************
1) Resident #1 was admitted to the facility on February 22, 2011 after treatment for a multi-drug resistant urinary tract infection (UTI) with sepsis (systemic infection). The resident had diagnoses including quadriplegia (paralysis of all extremities), seizure disorder, bipolar disorder, depression, and asthma.

The facility Discharge Against Medical Advice (AMA) Policy, dated June 2009, documents:
- a resident who wishes to leave the facility against the advice of the administration, attending physician, and interdisciplinary team will be considered a "self-discharge" AMA;
- documentation in nurses' notes and social work progress notes will reflect the circumstances surrounding the resident's decision to discharge AMA, and outline the information provided to the resident to assist in the decision making process; and
- a physician order will be obtained for "Discharge AMA."

The facility's Transfer and Discharge policy, included in the June 2010 publication, "Your Rights as a Nursing Home Resident in New York State," documents a nursing home may transfer or discharge a resident only after the interdisciplinary care team, in consultation with the the resident, determines:
- that the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met after reasonable attempts at accommodation at the facility;
- that the transfer or discharge is appropriate because the resident's health has improved sufficiently to the point where the resident no longer needs the services provided by the facility;
- that the health and safety of the resident or other individuals in the facilty would be otherwise endangered; and
- the resident has failed to pay for a stay at the facility.

The admission Minimum Data Set (MDS) assessment, dated March 1, 2011, documented the resident had normal cognitive ability; had the behavior of rejecting evaluation or care that is necessary to achieve the resident's goals for health and well-being; was non-ambulatory; was totally dependent upon staff for all activities of daily living (ADLs); had functional limitation in range of motion of upper and lower extremities on both sides, that interfered with daily functions or placed the resident at risk of injury; had an indwelling urinary catheter; was always incontinent of bowel; had a seizure disorder; had difficulty breathing when lying flat; was at risk of developing pressure ulcers; had 2 Stage II pressure ulcers when admitted to the facility; and received antidepressant and antipsychotic medications.

The CCP (comprehensive care plan), dated March 2, 2011, documented a plan for the resident to go out on pass with a responsible person (time parameter not specified). The goal was for the resident to benefit from the out on pass (OOP) experience with no ill effects.

Physician's orders, dated March 29, 2011, documented the resident could leave the facility "OOP with responsible party (time parameters not specified)."

A nursing progress note, written by the registered nurse (RN) Unit Manager on March 31, 2011, documented the resident said he wanted to go OOP on April 1, 2011. He stated he planned to depart on a public bus, and wanted to stay overnight. The note documented the RN told the resident he had an order for a day pass only.

A licensed practical nurse (LPN) progress note, dated April 4, 2011 at 11:04 PM, documented the resident "went OOP at approximately 6:30 PM. Has not returned as of 11 PM, unable to reach him by phone. Supervisor notified."

A late entry nursing progress note, written by an RN nursing supervisor at 12:24 PM on April 5, 2011, documented:
- on April 4, 2011 at approximately 10:45 PM, she was notified the resident was due to return at 9:00 PM that evening, and had not returned;
- the OOP log book did not specify the time the resident left the facility, nor the signature of a nurse who co-signed (with the escort) that the resident left the facility;
- staff were unable to contact the resident, family, and friends by telephone;
- staff were asked when the last bus would arrive that evening, and stated, "Close to 12:00 AM;" and
- the last bus arrived at 11:57 PM, and the resident was not on the bus.

A nursing progress note, written by the RN Unit Manager at 5:15 PM on April 5, 2011, documented the resident failed to return from OOP as ordered, and the resident was notified he would not be able to return to the facility "per policy." Adult Protective Services was notified, and the resident was advised to go to a hospital emergency room "to get further medical assistance if needed." The resident's physician was notified and provided an order for discharge AMA.

The facility Accident/Incident Report, signed by the former Assistant Administrator on April 5, 2011, documented the resident had been made aware of the OOP policy, and chose to remain OOP beyond the time authorized. A care plan modification was not needed, and the resident was discharged AMA on April 5, 2011.

The resident's April 2011 medication administration record (MAR), documented that between April 4, 2011 at 8:00 PM and April 5 at 12:00 PM while the resident was out on pass, he did not receive 9 doses of prescribed medications, including 2 doses of Keppra 500 mg (antiseizure drug).

An emergency medical service (EMS) report, dated April 5, 2011 at 1:27 PM, documented an ambulance was called that afternoon to evaluate the resident in a private apartment. The Resident told EMS staff he was "kicked out" of the facility. He stated facility staff had advised him to call 911, whereupon an ambulance would take him to the hospital to obtain his medications and bring him back (to the apartment). The EMS team directed the resident to contact a medical provider for his medications and left the resident in the company of several friends after he denied the need for emergency medical care.

A second EMS report, dated April 5, 2011 at 3:38 PM, documented the resident was brought to the hospital emergency department unresponsive, hypotensive (low blood pressure), and having seizures.

The hospital admission history and physical examination, dated April 5, 2011, documented the resident was admitted to the intensive care unit from the emergency department with diagnoses of hypotension, dehydration, seizure disorder, and urinary tract infection. The report documented a plan for case management consultation for placement of the resident upon his discharge from the hospital because he was not allowed to return to the facility.

A hospital physician's progress note, dated April 6, 2011, documented the resident stated he was staying with friends on April 4 and 5, 2011, and missed his medications. He stated he was having issues of sludge in his Foley (urinary) catheter, and foul-smelling urine prior to being brought to the emergency department on April 5, 2011. The physician's assessment included seizures due to being off his medication, and sepsis secondary to UTI.

Hospital case management notes, dated April 6, 2011 at 12:00 PM, documented the resident stated he did not return to the facility from a pass as planned on April 4, 2011, after he was unable to board a bus (which left him) at 7:30 PM that day. The resident stated he called the facility and talked to a nurse about his medications, and wanted to return to the facility. He stated he would "never go out on leave until his van gets fixed." A case management note written later that day, at 12:40 PM, documented an administrator from the facility stated the resident would not be re-admitted because the facility could not meet his "social needs."

A surveyor interviewed the current Assistant Administrator at 11:30 AM on April 13, 2011 regarding the facility Discharge Against Medical Advice policy. She was unable to explain why the AMA policy does not include a procedure for staff to follow if a resident fails to return to the facility at the time previously planned. She was also unable to explain why the policy does not contain a procedure to ensure written information is given to residents advising them of the facility AMA discharge policy. When asked about staff responsibility to assist Resident #1 to return to the facility in a timely manner when using public transportation, the Assistant Administrator stated this was left up to the resident because he was alert and oriented.

A surveyor interviewed the RN Unit Manager at 2:00 PM on April 13, 2011. When asked about staff responsibility to verify the resident would have been able to safely return to the facility on a public bus on the evening of April 4, 2011, the RN stated the only facility requirement was for the resident to have an escort. She stated the resident telephoned her at 8:00 AM on April 5, 2011, and told her he was unable to call the facility while he was OOP on April 4, 2011 because his cell phone could not access service. He stated the bus he planned to take back to the facility did not arrive. The RN stated she spoke to the resident later that day, and told him to go to the local hospital to obtain his medications. When asked about the facility policy for AMA discharge, the RN stated the facility will not allow a resident to return in the event of intentional elopement.

A surveyor interviewed the Medical Director at 11:50 AM on April 15, 2011, regarding the decision to discharge the resident AMA after he failed to return from pass at a predetermined time on April 4, 2011. The Medical Director stated the facility policy does not need to document that a resident who leaves the facility AMA will not be allowed to return. He stated, "The resident "discharged himself."

A surveyor interviewed the social worker at 12:45 PM on April 15, 2011. She stated that on April 5, 2011, she called Adult Protective Services staff to notify them the resident was discharged AMA that day, and they were confused about the reason the facility would not allow the resident to return to the facility. The social worker said she told them the resident could not return to the facility because he had a day pass, and stayed overnight. The social worker stated the resident called her on April 5, 2011, and said he was on his way to the hospital because his urinary catheter bag had burst. She stated the resident was not provided written notice he would be discharged from the facility if he failed to return from OOP on time.

In summary, the facility failed to ensure the resident would not be discharged from the facility unless the discharge was necessary for the resident's welfare and needs as:
- he was discharged AMA after he did not return from a pass at a predetermined time;
- the facility refused to readmit him when he wished to return to the facility.

10NYCRR 415.3(h)(1)(i)(a-c)

F284 483.20(l)(3): REQUIREMENTS FOR POST-DISCHARGE PLAN OF CARE

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: May 21, 2011

When the facility anticipates discharge a resident must have a discharge summary that includes a post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment.

Citation date: April 18, 2011

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY00099625), it was determined for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" (OOP) medical orders, the facility failed to ensure a post discharge plan of care was developed with the participation of the resident and his/her family, which will assist the resident to adjust to his/her new living environment. Specifically, the facility discharged Resident #1 against medical advice ( AMA) without an appropriate discharge plan, resulting in the need for emergency care and hospitalization for serious medical problems. This resulted in Immediate Jeopardy and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders.
Findings include:

The Immediate Jeopardy situation was removed on April 18, 2011 prior to survey exit, based on the following corrective actions taken by the facility:
- OOP orders for all residents were discontinued;
- a revised OOP assessment and care plan was developed;
- implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges;
- implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident;
- supervisory review of the results of each revised RN OOP assessment;
- supervisory notification of the Medical Director, who (alone) would provide a resident OOP order;
- all staff were in-serviced on the new policies and procedures;
- the resident council was notified of the revised OOP procedures; and
- facility administrative staff monitored all staff to ensure compliance with the new policies and procedures.

*******************************************************
1) Resident #1 was admitted to the facility on February 22, 2011 after treatment for a multi-drug resistant urinary tract infection (UTI) with sepsis (systemic infection). The resident had diagnoses including quadriplegia (paralysis of all extremities), seizure disorder, bipolar disorder, depression, and asthma.

The facility Discharge Against Medical Advice (AMA) Policy, dated June 2009, documents that a resident who wishes to leave the facility against the advice of the administration, attending physician, and interdisciplinary team, will be considered a "self-discharge" AMA.

The facility's Transfer and Discharge policy, included in the June 2010 publication, "Your Rights as a Nursing Home Resident in New York State," documents that when a resident is transferred or discharged from a nursing home, the resident has the right to receive sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility, "including an opportunity for (the resident) to participate in deciding where to go."

The admission Minimum Data Set (MDS) assessment, dated March 1, 2011, documented the resident had normal cognitive ability; was totally dependent upon staff for all activities of daily living (ADLs); had functional limitation in range of motion of upper and lower extremities on both sides, that interfered with daily functions or placed the resident at risk of injury; had an indwelling urinary catheter; was always incontinent of bowel; had a seizure disorder; had difficulty breathing when lying flat; was at risk of developing pressure ulcers; and had 2 Stage II pressure ulcers when admitted to the facility.

The facility Accident/Incident Report, signed by the former Assistant Administrator on April 5, 2011, documented the resident did not return from a pass on the evening of April 4, 2011. The resident had been made aware of the out on pass (OOP) policy, and chose to remain OOP beyond the time authorized. A care plan modification was not needed, and the resident was discharged AMA on April 5, 2011. The report did not specify a discharge plan with interventions to ensure the resident's health and safety.

Review of the resident's medical record revealed there was no assessment of the resident's medical and safety needs, and identification of an individual who would be responsible during this disabled resident's OOP time.

The hospital admission history and physical examination, dated April 5, 2011, documented the resident was admitted to the intensive care unit from the emergency department with diagnoses of hypotension, dehydration, seizure disorder, and urinary tract infection. The report documented a plan for case management consultation for placement of the resident upon his discharge from the hospital because he was not allowed to return to the facility.

A surveyor interviewed the resident's physician via telephone at 10:50 AM on April 15, 2011. He stated the resident failed to return from a pass on April 4, 2011, and a nurse telephoned him on April 5, 2011 to request an order to discharge the resident from the facility per policy. He stated he was required to follow facility policies.

In summary, the facility failed to protect the health and safety of this resident with multiple medical problems as:
- the resident was discharged AMA while OOP without an appropriate discharge plan, resulting in the need for emergency care and hospitalization for serious medical problems;
- the facility failed to assist the resident to develop a care plan for the OOP time and for later when the facility discharged the resident AMA.

10NYCRR 415.11(d)(3)

F203 483.12(a)(4)-(6): PROPER NOTICE BEFORE TRANSFER/DISCHARGE OF RESIDENT

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: May 21, 2011

Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.

Citation date: April 18, 2011

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY00099625), it was determined that prior to transferring or discharging a resident, the facility did not notify the resident and family member or legal representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Discharge notice concerns affected 1 sampled resident (Resident #1) of the 177 residents with "out on pass" medical orders. Specifically, the facility did not provide a notice to the resident and his family prior to discharging him AMA (against medical advice) when he did not return to the facility while being out on pass (OOP), and did not provide the resident/family with written notice of the right to appeal the resident's discharge. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #1 was admitted to the facility on February 22, 2011 after treatment for a multi-drug resistant urinary tract infection (UTI) with sepsis (systemic infection). The resident had diagnoses including quadriplegia (paralysis of all extremities), seizure disorder, bipolar disorder, depression, and asthma.

The facility Discharge Against Medical Advice Policy, dated June 2009, documents:
- a resident who wishes to leave the facility against the advice of the administration, attending physician, and interdisciplinary team will be considered a "self-discharge" AMA;
- documentation in nurses' notes and social work progress notes will reflect the circumstances surrounding the resident's decision to discharge AMA, and outline the information provided to the resident to assist in the decision making process; and
- a physician order will be obtained for "Discharge AMA."

The facility's Transfer and Discharge policy, included in the June 2010 publication, "Your Rights as a Nursing Home Resident in New York State," documents a nursing home must:
- inform the resident and the designated representative, verbally and in writing, about readmission regulations at the time of admission to the facility, and again at the time of transfer for any reason;
- readmit the resident, if the resident has been in residence at least 30 days;
- before transferring or discharging a resident, notify the resident and a family member or designated representative both verbally and in writing of the transfer or discharge and the reasons for it;
- include in the written notice information about the right to appeal the transfer or discharge; and
- provide the notice of transfer or discharge at least 30 days prior to the expected date of transfer or discharge.

The admission Minimum Data Set (MDS) assessment, dated March 1, 2011, documented the resident had normal cognitive ability.

A nursing progress note, written by the RN Unit Manager at 5:15 PM on April 5, 2011, documented the resident failed to return from a pass as ordered, and the resident was notified he would not be able to return to the facility "per policy." Adult Protective Services was notified, and the resident was advised to go to a hospital emergency room "to get further medical assistance if needed." The resident's physician was notified and provided an order for discharge AMA.

The facility Accident/Incident Report, signed by the former Assistant Administrator on April 5, 2011, documented the resident had been made aware of the out on pass (OOP) policy, and chose to remain OOP beyond the time authorized. A care plan modification was not needed, and the resident was discharged AMA on April 5, 2011.

The hospital admission history and physical examination, dated April 5, 2011, documented the resident was admitted to the intensive care unit from the emergency department with diagnoses of hypotension, dehydration, seizure disorder, and urinary tract infection. The report documented a plan for case management consultation for placement of the resident upon his discharge from the hospital because he was not allowed to return to the facility.

A surveyor interviewed the Assistant Director of Nursing (ADON) at 8:40 AM on April 15, 2011. The ADON stated that prior to April 5, 2011, the resident's medical record contained no documented evidence he was informed he would be discharged AMA if he failed to return to the facility at a predetermined time after being OOP.

A surveyor interviewed the social worker at 12:45 PM on April 15, 2011, regarding the information that was provided to the resident when he was discharged AMA. She stated that after a meeting she attended on the morning of April 5, 2011 with the facility Administrator, former Assistant Administrator, Director of Nursing, and RN Unit Manager, the decision was made not to allow the resident to return to the facility. The social worker stated the former Assistant Administrator then telephoned the resident to tell him of his discharge. Later that day, the resident telephoned the social worker and told her he was on his way to the hospital because his urinary drainage bag had burst. He told the social worker that he had been trying to return to the facility, and received a telephone call from the facility instructing him not to return to the facility. The social worker stated the facility Discharge AMA policy does not specify that a resident who does not return to the facility at the designated time is discharged AMA. She stated that prior to the resident's leaving to go out on pass on April 4, 2011, she did not tell him he would be discharged AMA if he remained out of the facility overnight. The social worker stated she telephoned the resident, who remained hospitalized, on the morning of April 15, 2011, and the resident asked, "Are you still mad at me?"

In summary, the facility did not provide a discharge notice to the resident and his family member/legal representative as required by State regulation.

10 NYCRR 415.3(h)(1)(iii)(a-c)