James Square Health and Rehabilitation Centre

Based on staff interviews and record reviews conducted during the abbreviated survey (#NY00087080), it was determined the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 sampled resident (Resident #1) reviewed for a change in status. Specifically, the facility did not ensure Resident #1 received care in a timely manner related to the deterioration of her left lower extremity, including its lack of circulation. This resulted in actual harm that is not immediate jeopardy.
Findings Include:

Resident #1 was admitted to the facility on February 26, 2010 for long term care with diagnoses including dementia, left hip fracture with reconstructive surgery in December 2009, and a Stage III pressure ulcer on left heel.

The resident's " Pain History and Assessment " , dated May 26, 2010 documented the resident experienced pain " due to left heel ulcer " described as " aching and throbbing " when her left foot was touched or moved. The assessment did not include a description of the foot.

Review of nurses notes, dated May 27, 2010 revealed nursing documented the resident refused medications. There was no documented nursing assessment regarding the status of the resident's left foot for this date.

A nursing progress note, dated May 28, 2010 at 9:30 PM, documented a " new order received to continue treatment to left heel " with Collagenase and Kling with everyday changes for 15 days. There was no documented nursing assessment of the resident's left foot for this date.

CNA #1 was interviewed (on June 23, 2010 at 12:45PM) and stated when he performed morning care for the resident on May 29, 2010, he noticed the resident's foot was blue and informed the nurse. CNA #1 stated he elevated the resident's foot with 2 pillows and the color returned to normal. The CNA stated he informed the licensed practical nurse (LPN) #3 of his observations. The CNA stated he was off duty June 1 through June 3, 2010.

Review of nursing notes, dated May 29, 2010, revealed nursing documented the resident refused medications. There was no documentation in these nursing notes regarding the resident's foot. There were no nursing notes documented on May 30 or May 31, 2010 in the resident's medical record.

The resident's June 1, 2010 MDS assessment documented the resident's activities of daily living (ADLs), related to transferring and hygiene, declined from the March 2010 MDS and the resident now required " total " assistance. The June 2010 MDS documented the resident continued to have a Stage III " pressure " ulcer, and " foot problems " .

When CNA #2 was interviewed (on June 23, 2010 at 1:00PM), she stated she saw the resident on June 1, 2010. She said the resident's mid calf down to her toes was " purple " , " even after elevating the foot, the color remained purple. " CNA #2 stated she told LPN #2, who said she already spoke with NP #1.

The next LPN nursing note was dated June 1, 2010 at 12 PM and documented the resident's left lower extremity was " very cold to the touch, bluish in color-poor circulation. " The note specified " color does return slowly back to normal. Will have NP assess. "

Review of the resident's medical record revealed there was no documentation from the NP #1 or NP #2 on June 1, 2010 that specified an NP saw the resident on that date.

The registered nurse (RN) Manager was interviewed (on June 23, 2010 at 11:00 AM.) She stated when she assessed the resident on June 1, 2010, the resident's heel was a light purple, " but the wound itself looked fine. " She stated NP #1 looked at the resident's foot on that date, and " thought the change in condition was from PVD. "

The surveyor interviewed NP #1 (on June 23, 2010 at 12:30 PM) who stated she did not remember seeing the resident on June 1, 2010. The RN Manager was asked to join the interview with NP #1. The RN Manager stated NP #1 assessed the resident on June 1, 2010 and said LPN #2 told her that NP #1 saw the resident on June 1, 2010.

The surveyor conducted a telephone interview with LPN #2 (on June 29, 2010 at 11:45 AM) regarding the status of the resident's left lower leg and foot from May 29, 2010 to June 6, 2010. LPN #2 stated " it only started with the resident's toes. " The LPN was asked if the attending physician saw the resident. She stated she did not know why the physician did not assess the resident when he did rounds with the RN Manager on June 2, 2010. LPN #2 stated she thought NP #1 saw the resident more than once " that week " , and said the NP told her the resident had PVD and staff should try to elevate the resident's leg as much as possible.

On June 2, 2010 at 10AM, an RN note documented the resident's skin assessment was done and the area to the left heel continued to close around the slightly purple tissue, due to poor circulation. The note specified " NP assessed " the resident to have PVD (peripheral vascular disease). The nursing note documented they were to elevate the resident's leg on a pillow, " continue treatment and monitor " .

During the interview with CNA #3 (on June 23, 2010 at 1:15PM) she stated that on June 2, 2010, the resident's leg was purple from the mid calf down, and it remained purple with elevation. " I told the nurse it was purple, but from my knowledge, they were just elevating the leg. "

The attending physician was interviewed via telephone (on August 18, 2010 at 9:45 AM) regarding his awareness of the resident's left lower extremity. The physician was asked if the RN Manger informed him when they did rounds together at the facility on June 2, 2010. He replied that " the nurse manager did not tell me. "

LPN #2 was interviewed (on June 29, 2010 at 11:45 AM) and stated she " thought the nurse manager did rounds with the physician " on June 2, 2010, but she was unsure what was discussed.

On June 2, 2010 at 10:00 AM, the RN Manager nursing note documented an area on the resident's left heel was " extremely purple; left heel wound starting to look worse due to poor circulation. " The note specified the resident's leg was elevated on the pillow; her foot was " purple and cool to touch. The NP to assess again. "

At 10:15 AM on June 3, 2010, and LPN #1 nursing note documented the dressing was changed to the resident's left heel, revealing a moderate amount of bloody drainage. The foot and heel were noted to be very purple and the wound looked " worse due to poor circulation. " The note documented the resident was " non compliant with keeping the left leg elevated on pillows. " The note documented the " nurse manager (was) aware " , and NP #1 was " to assess the resident in the morning. "

During a telephone interview with the RN Manager (on October 6, 2010), the RN was asked why the attending physician was not notified of the status of the resident's left lower extremity. The RN Manager stated she did not call the physician " because the NP (NP #1) was following the resident, and knew " the resident's status.

An LPN #1 nursing note at 1:30 PM on June 3, 2010 documented the family visited the resident and " held the (resident's) left leg up continually for a half hour or so. " The note documented " color returned during that time to the left foot. " The resident was very upset and did " not want anyone to touch her left foot. "

The surveyor interviewed NP #1 (on June 23, 2010 at 12:30 PM) who stated she did not work on June 2 and June 3, 2010. The NP stated she did not see the resident until June 4, 2010.

The facility's other NP, (NP #2) was interviewed on June 23, 2010 at 12:30 PM. She stated she worked on June 2 and June 3, 2010, but did not see the resident on those days.

Review of the 24 hour report for June 1 to June 3, 2010, revealed no documentation entries that specified nursing communicated the status of the resident's left lower extremity to NP #1 or NP #2 during that time.

The RN Manager provided the surveyor with her written statement (dated June 16, 2010) that specified on June 3, 2010 the resident's whole foot was purple, cool to touch and was able to feel a faint pedal pulse. She documented she did not call the attending physician, because when the foot was elevated, it would return back to normal color and a pedal pulse was detected.

The RN Manager, interviewed (on June 23, 2010 at 11:00 AM), stated LPN #1 went to her on June 3, 2010 and said the resident's foot " looked worse. " From the mid calf, down to the whole foot, was a darker purple, but a pulse was detected. The resident's foot was elevated and returned to normal color. The RN stated the resident's family came in and she told them the NP #1 was off and she would ask NP #1 for a consultation on June 4, 2010.

On June 3, 2010, the resident's comprehensive care plan (CCP) was updated and documented the resident's left heel had " decreased blood flow to wound area, dark purple/black; NP was to assess. " The CCP specified staff were to " keep left foot/leg elevated at all times on pillows. "

On June 4, 2010 at 12:40 PM, a nursing note documented NP #1 ordered arterial Doppler studies (circulation test) on both of the resident's legs, scheduled for June 7, 2010.

When CNA #1 was interviewed (on June 23, 2010 at 12:30 PM), he stated when he worked on June 4, 2010, the resident's foot from the ankle down was severely blue, and it returned to normal color when it was elevated.

The RN Manager was interviewed (on June 23, 2010 at 11:00 AM) regarding the status of the resident's left leg on June 4, 2010. The RN Manager said NP #1 came in during that morning, and tried to get a Doppler study, " but there was no availability until June 7, 2010. "

NP #1's " acute note " , (dictated and typed on June 11, 2010 regarding her June 4, 2010 visit) documented " staff and the resident's family have noticed her left foot has become more discolored. " This NP note documented the resident " states her foot aches this morning " and would not be more specific. NP #1 noted the resident had dementia, PVD, a history of long term ulcer on her left heel, and " chronic pain in her foot " The note documented staff " noticed particularly the sole of her foot to be more discolored, a darker purple in color. " NP #1 specified the resident's foot was " cool to touch " and she was " not able to palpate pedal pulses. " The NP documented she " did not observe the wound " and wrote the resident's " dressing was intact " , with no drainage on the dressing. NP #1's note documented the resident's lower leg was " pale in color, slightly cool to touch " , and the resident's " knees (were) crossed " and she was " kicking her foot in the air. " NP #1's note specified staff reported the resident's family " would like and evaluation done. " NP #1 wrote she contacted the outside radiology resting agency who would not be able to do the Doppler study until June 7, 2010, due to the timing of their technician. " NP #1 documented she " would follow up when those results are available " , staff were to " continue to monitor it and call the on-call physician for any other changes. "

NP #1 was interviewed (on June 23, 2010 at 12:30 PM) regarding the status of the resident's leg and foot on June 4, 2010. The NP stated she did not get a pedal pulse on the left foot. The resident was lying with her foot in a reclining wheelchair with her legs elevated. The left leg was cool and pale with the sole of the foot a reddish purple color with no pulse. NP #1 stated she did not send the resident to the emergency room (ER) " because it was the sole of her foot and not the entire leg. " She stated there were no drastic changes in the resident at that time. She said she ordered the Doppler study that was scheduled for June 7, 2010 and called the family who were " ok with that. " She said she did not inform the resident's attending physician, as she " was taking care of it. " June

Review of physician orders and nursing notes for June 4, 2010, revealed no documented NP order for nursing staff to notify the on-call physician " for any other changes. "

At 9:00 PM on June 4, 2010, LPN #1's nursing note documented the resident was only " out of bed for supper due to poor circulation in the left leg " , and was non-compliant with keeping it elevated when up in the wheelchair. The note specified the color to her left leg was " purple at times " , was " cool to touch " , and specified the resident cried out when touched.

LPN #1 was interviewed (on June 23, 2010 at 11:44 AM) who stated the resident's leg " was worsening " on June 4, 2010 (Friday). She stated she had never seen the resident's leg " that purple before. " She said the resident's leg was cool and her left heel was purple. She said she brought the RN Manager in to check it. LPN #1 stated the RN told NP #1 saw it, said it was PVD, and advised them to keep the resident's leg elevated. LPN #1 said the resident was in pain and it progressed until she was sent out. LPN #1 stated that you could tell the resident's circulation was decreasing by the changes to the area. When LPN #1 was re-interviewed (on October 6, 2010 at 2 PM), she was asked if there was a reason she did not call the resident's attending physician when she noted the resident's left leg was " worsening " . LPN #1 responded that she " didn't remember. "

On June 6, 2010 at 6:00 AM, a nursing note documented the resident refused morning medications and was calling out again most of the shift. The note specified the resident " calls out when repositioned in bed " . At 1:00 PM, LPN #2 nursing note documented the resident was " kept in bed this shift to elevate the left leg was much as possible. " The note specified the resident's foot and heel were " bluish black " , and " now " the top of her foot and her toes were " swollen " . The resident was " crying out on and off all morning. "

Review of the 24 hour report from June 4 to June 6, 2010, revealed no documented entries that specified nursing communicated the status of the resident's left lower extremity to NP #1 or NP #2 during that time.

When NP #1 was interviewed (on June 23, 2010 at 12:30 PM) regarding the status of the resident's left leg and foot, she stated she did not see the resident on June 5 or June 6, 2010.

At 6:30 AM on June 6, 2010, RN 32 nursing note documented " advised of status of resident's foot and leg - left foot dark purple to black and extending up to (the) knee - purple and green in color, foul odor. " The note specified the resident's left heel had an " unstageable " wound. The note specified the resident's son was notified and aware of the changes. The nurse documented the physician was notified at 6:35 AM, and ordered the resident to be transported to the hospital emergency room (ER) for evaluation. At 7:07 AM, a nursing note documented an ambulance transported the resident to the hospital.

When LPN #2 was interviewed (on June 29, 2010 at 11:45 AM), she stated that on June 6, 2010, the resident's toes and foot were darker. She said she " called the supervisor " and the resident was sent out to the hospital.

The facility's patient transfer form, dated June 6, 2010, documented the resident needed an " evaluation of the left leg " due to a " heel ulcer, poor circulation, (and) increased pain. The handwriting on this transfer form documented the resident's left leg was " progressively worsening since June 1, 2010, increased pain. No circulation, and swollen/blue black. "

The June 6, 2010 physician's ER record, documented " per report form the nursing home " , the resident " started having some skin changes on May 29, (2010) that subsequently progressed; " and was " subsequently found to have a cold, pulseless left lower extremity on June 1, 2010. " In the emergency room, the resident was described as being hypotensive (low blood pressure), tachycardiac (rapid heart beat), and screaming in pain. The resident was noted to have a left lower extremity that " was obviously gangrenous, extending up into the calf. " There was an odor present, with notable darkened skin up to the mid calf. The patient had severe pain on any movement, with cold pulseless foot, and a distinct odor present. The note specified the resident cried out in agony, with any movement or palpation. Surgery was consulted and they recommended amputation above the knee. The family decided to allow the patient comfort and dignity in the final days of her life, without surgery. The patient was admitted to Comfort Care service.

The hospital discharge summary, dated June 11, 2010 documented resident expired at 11:40 AM on June 11, 2010.

The resident's attending physician returned a call from the surveyor (on August 4, 2010) and left a message that he did not see the resident from May 27, 2010 through June 6, 2010, according to the facility's records. He stated he saw the resident prior to that time.

When the resident's attending physician was interviewed via telephone (on August 19, 2010 at 11:00 AM), he stated he reviewed the resident's medical record and it was " concerning " that there was no (pedal) pulse. He said he would have had the Doppler performed immediately. He stated that on June 4, 2010 at 9:00 PM, nursing notes documented the resident's leg was cool to touch and there was no pulse. He stated that information revealed " things were changing " and that a " stat " (immediate) Doppler and trip to the emergency room were indicated. The physician stated that on June 5, 2010 at 1:00 PM, there was a critical change, based on nursing notes, when the resident's foot was a purplish color and distending.

In summary, the resident experienced harm, as the facility:

-did not monitor the status of the residents left lower extremity when significant changes occurred;
-did not notify the resident's physician when her left leg and foot became purple in color, and cool to the touch (from June 1, 2010 until June 6, 2010);
-did not ensure the resident received prompt medical evaluation when her foot was identified to have no pulse on June 4, 2010 and an outpatient Doppler was not available for three days;
-did not ensure the resident was evaluated by a medical provider on June 5, 2010, when resident's foot and heel were " bluish black " , and to top of her foot and her toes were noted to be " swollen " .

10 NYCRR 415.12