Putnam Nursing & Rehabilitation Center

Based on interview and record review, a resident received Haldol (an antipsychotic drug) without documented evidence of adequate indications to justify the use of this drug, without evidence of interventions attempted to manage behaviors prior to the use of Haldol and without monitoring of the resident's response to the drug in order to determine the effectiveness of its use. This was evident for one of fourteen residents reviewed for the use of psychoactive drugs and resulted in the potential for more than minimal harm (Resident #6).

The findings are:

Resident #6 was admitted to the facility on 8/12/10 with diagnoses including Dementia. The resident's admission Minimum Data Set assessment, completed on 8/26/10, identified that she was sad, resistive to care, had memory problems, severely impaired decision-making ability and difficulty making herself understood and being understood by others. The resident's primary language was not English but according to the Care Plan for Communication, initiated 8/31/10, the resident's family reported that she was confused when communicating in both English and her native language.

The resident had admission and current Physician's Orders, dated 8/12/10 and 9/23/10 respectively, for the use of Haldol as needed for extreme agitation.

According to the Medication Administration Records (MAR) for 8/10 and 9/10, the resident received Haldol at 1:45PM on 8/13/10. An entry in the Nurse's Notes on that date stated that the nurse observed signs and symptoms of anxiety such as constantly talking in her primary language, reaching out for something unknown, constant body movements while sitting in the wheelchair and trying to get up. The note further stated that Haldol was given with minimum effect. There was no documented evidence of measures attempted to address the resident's behaviors prior to administering Haldol.

The same MARs also revealed that the resident received Haldol on three other occasions in the day time during that period, on 8/30/10, 9/3/10 and 9/29/10, for increased agitation. Nurse's Notes for those dates revealed no evidence of extreme agitation indicative of the need to use Haldol to manage the resident's behavior. There was no documented evidence of interventions attempted to manage the resident's unspecified behaviors prior to giving the antipsychotic drug and no evidence of the resident's response to the Haldol.

The Licensed Practical Nurse (LPN) was interviewed at 10:15AM on 10/5/10 about the resident's behavior and agitation. The LPN stated that the resident was sometimes resistive to cares and eating and that she sometimes tried to get up from the wheelchair. The LPN stated that the resident's behaviors were easily altered.

The RN Clinical Care Coordinator was interviewed at 3:30PM on 10/5/10. She stated that behavior monitoring should be found in the Nurse's Notes. The RN reviewed the resident's clinical record and stated that she could not tell what behaviors, extreme or otherwise, prompted the use of the Haldol for the resident. The RN did not identify what interventions were attempted to manage the unspecified behaviors for the resident prior to giving her Haldol. The RN stated that monitoring to determine the effectiveness of the use of Haldol was not done.

415.12(l)(1)

Based on observation, interview and record review, the facility did not identify the risk of potential entrapment, contact injury or other accidents related to the use of side rails (bed rails) for a cognitively impaired resident with agitated behaviors and the ability to move about in bed independently. This was evident for one of three residents reviewed for the use of side rails and resulted in the potential for more than minimal harm that is not immediate jeopardy (Resident #6).
The findings are:
Resident #6 has diagnoses including Dementia. She was hospitalized for a two week period and then admitted to the facility on 8/12/10 for rehabilitative services and subsequent long-term care.
The resident's admission Minimum Data Set assessment, completed on 8/26/10, identified that she had memory problems, severely impaired decision-making ability and difficulty making herself understood and being understood by others. She was also assessed at that time to be non-ambulatory and totally dependent on a staff member to move about in bed.
Record review revealed that the use of "2 full" side rails (actually four half side rails referred to by staff members as two full side rails, as clarified with the RN unit Clinical Care Coordinator) was continuously in place throughout the resident's stay in the facility. This was documented in the Admission Physician's Orders of 8/12/10 and current 9/23/10 Orders, as well as the Initial Admission Side Rail Assessment completed by the Licensed Practical Nurse (LPN) on 8/12/10 and the most recent Side Rail Assessment completed by the Registered Nurse Clinical Care Coordinator (RN) on 9/1/10.
An entry in the Admission Notes by an LPN during the 3:00PM - 11:00PM shift on 8/12/10 stated that the resident attempted to get out of bed a few times and that she would dangle her legs over the rails. The note further stated that the side rails were up to prevent any falls.
The resident's Care Plans to address the use of side rails and the prevention of falls and injuries were initiated on 8/23/10, and most recently reviewed on 9/28/10, by unit the RN. Those care plans stated that full side rails with long bolster pillows adjacent to the rails were in use because the resident had a history of climbing from bed resulting in falls. The care plans also included discussion on 9/1/10 and 9/28/10 with the resident's family who requested the indefinite use of full side rails to prevent the resident from falling from bed. Entries by the RN stated that the family was educated about the risks and benefits involved with the use of full side rails and that the family and the interdisciplinary team agreed that the benefit of side rail use outweighed the risks. There was no documented evidence of what benefits or risks were identified or considered in making that conclusion. RN entries further stated that the issue would be reevaluated if the resident became more active at night or began to climb over the side rails.
The resident was observed awake in bed with four half side rails raised at 2:30PM on 10/5/10. A bolster was in place along the rails on one side of the bed. No bolster was in place on the other side so that the gap between the upper and lower rails was exposed. The resident made several attempts to sit up in bed by rocking and using hers arms for support. She then thrust her legs against the rails and one leg passed through the space between the upper and lower side rail on the side of the bed without a bolster against the rails. The resident laid down, withdrew her legs and then inserted both legs between the side rails.
The CNA assigned to care for the resident several times a week, during the day and evening shifts, entered the resident's room and was interviewed immediately following this observation. The CNA stated that the resident is strong and sometimes removes the bed bolsters even though they are tied under the bed. The CNA stated that the resident tries to sit up in bed and wiggles her legs around the rails. She stated that she puts the resident to bed as late as possible in the evening because she is agitated in the evening time and restless in bed.
The LPN in charge was interviewed at 2:45PM on 10/5/10. She stated that the resident was more active over the last two weeks. The LPN stated that the resident had thrown the bolsters out of bed on a recent morning.
The RN Clinical Care Coordinator was interviewed at 3:30PM on 10/5/10. She stated that the resident's behavior, strength and functional status had improved over the past two weeks. The RN stated that she was hoping to eliminate the use of the two lower rails at some point if the interdisciplinary team and the family agreed. The RN stated that, at this time, she believed the risk of resident injury from the rails was outweighed by the benefit of keeping the resident from falling out of bed.
415.12(h)(1)(2)

Based on observation, interview and record review, a resident, who was previously assessed to be totally dependent on staff to eat, did not promptly receive appropriate care to restore her ability to eat independently after multiple staff members identified improvement in her capacity to feed herself. This was evident for one of seven residents reviewed for activities of daily living and resulted in the potential for more than minimal harm (Resident #6).

The findings are:

Resident #6 has diagnoses including Dementia. She experienced a decline in mental and physical status at home, was hospitalized and subsequently admitted to the facility on 8/12/10.

The resident's Care Plan for ADL Function (Activities of Daily Living), initiated on 8/23/10 and still currently in use, stated that she needed to be fed by staff. According to her Minimum Data Set assessment, completed on 8/26/10, and Resident ADL Care Plan currently in use by the CNAs (Certified Nurse Aides) the resident required total assistance to eat.

The resident was observed during lunch in the second floor dining room on 10/4/10 being totally hand-fed all of her food and drinks by two different CNAs. During the meal, the resident scooped up some ground meat in her hand and tried to eat it. A CNA told the resident not to do that and continued to feed her. The resident reached for a spoon and another CNA told the resident not to touch the spoon. The resident reached for a dish of dessert. A CNA pushed her hand away from the dish and continued to feed her.

The resident was observed during breakfast on 10/5/10 being totally hand-fed by a Licensed Practical Nurse. The resident picked up a knife and the LPN gently removed it from her hand. The resident reached for food on her plate, a spoon and a milk carton while the LPN was feeding her. The LPN pushed the resident's hand away each time.

Nurse's Notes entries by two different LPNs on 10/1/10, 10/2/10 and 10/3/10 stated that the resident was able to feed herself and also stated that she needed adaptive equipment.

The LPN who noted that the resident could feed herself but needed adaptive equipment, and who fed the above breakfast meal to the resident, was interviewed at 10:30AM on 10/5/10. The LPN stated that the resident needed adaptive equipment but did not state how she came to that conclusion. She stated that the resident tries to use her hands to eat and she prevents her from doing that because she would get sticky.

The RN Clinical Care Coordinator was interviewed at 11:30AM on 10/5/10. She stated that the resident's functional status had improved over the past couple of weeks. The RN stated that a CNA and an LPN had informed her that the resident had been trying to feed herself. The RN stated that she had referred the resident to the Occupational Therapist for evaluation. The RN stated that the resident should be allowed to participate in feeding herself in the meantime.

The resident was observed during lunch on 10/5/10. A CNA set up the items on the food tray including cutting the resident's chicken cutlet. An LPN placed a fork in the resident's right hand. The resident immediately began to eat independently. She successfully ate her broccoli spears and pieces of chicken and drank juice from a cup. She was also able to eat noodles with sauce and peas with the fork.

415.12(a)(2)

Based on record review and interview, the facility did not ensure that necessary interventions were implemented to prevent a resident from exceeding acceptable weight parameters. This was evident for 1 of 7 residents (Resident #16) reviewed for weight and nutrition.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 16 is a 94 year old female with diagnoses including Senile Dementia with Depression and Anxiety, Syncope, Hypertension, and Psychotic Disorder. According to the full Minimum Data Set (MDS, an assessment tool), dated 12/11/09, the resident has moderately impaired cognition with long and short term memory problems. This MDS noted that the resident's weight was 129 lb and that the resident left 25% or more of her food uneaten at most meals.

According to her Nutrition/Hydration Comprehensive Care Plan(CCP)dated 3/11/10, the resident was noted to be at risk nutritionally due to leaving 25% of food uneaten, use of dietary supplement and diagnoses (not specified). One of the goals reflected on this CCP was for the resident to not have excessive weight change (i.e. plus or minus 3 lb). The IBW(Ideal Body Weight) documented on the CCP was noted to be between 108-132 lb. Some of the planned interventions were to monitor her weight and labs, encourage meal completion, and offered her 60 cc of supplements three times a day (2 Cal HN) which provided 360 calories daily.

The Quarterly Nutrition/Hydration CCP and Nutrition Risk Assessment dated 6/23/10, indicated that the resident's weight was in her usually body weight range (actual weight 136.8 lb) and that her goals remained appropriate. The plan was to continue the interventions mentioned above.

The resident's monthly weight record for 2010 revealed a steady increase in her weight from June 2010 as follows: July - 141.8 lb, August -142.6 lb and September - 146.9 lb. There was no documented evidence of any further follow-up by the dietary staff.

On 9/23/10 the Physician gave a telephone order for the 2 Cal HN to be discontinued secondary to weight gain. A review of the September 2010 and October 2010 Medication Administration Records revealed that the nursing staff continued to offer the supplement to the resident.

In a telephone interview with the Dietician on 10/7/10 at 2PM, she was unable to provide further information as to why the dietary supplement was not discontinued after it was documented in the June 2010 nutritional assessment that the resident had achieved her usual body weight.

The Licensed Practical/Medication Nurse was interviewed on 10/7/10 in the afternoon. He stated that he was not aware of the Physician's order to discontinue the supplement.

415.12 (i)(1)

Based on interview and record review, a resident who was previously continent of bladder, and developed incontinence, was not promptly provided with appropriate care to restore as much bladder function as possible. This was evident for one of twelve residents reviewed for incontinence and resulted in the potential for more than minimal harm (Resident #21).
The findings are:
Resident #21 is a 54 year old cognitively intact male with diagnoses including Schizophrenia, Anxiety Disorder, Chronic Obstructive Lung Disease and a history of seizures. According to his most recent Minimum Data Set assessment, completed on 9/14/10, the resident's decision-making abilities were moderately impaired.
The resident's Care Plan for Urinary Incontinence had entries from 3/16/10 - 9/15/10 that stated that he was usually continent of urine with rare episodes of incontinence if rushed or upset. The 9/10 Resident ADL Care Plan, currently in use by the CNAs (Certified Nurse Aide), noted that the resident was continent of urine and not on a toileting schedule because he was self- motivated. The 9/10 and 10/10 ADL Flow Sheets were reviewed and stated that the resident required no assistance from the CNAs for toilet use.
The resident was incontinent of urine on 9/8/10, 9/20/10 and 9/21/10, according to entries in the Nurse's Notes. Specimens to check the resident's urine for infection (UTI) were ordered on 9/21/10, obtained and sent to the lab on 9/22/10. There was no evidence in the clinical record that interventions were implemented to try to identify factors other than a UTI that possibly contributed to the resident's incontinence. There was no evidence that a toileting schedule or other interventions were implemented to attempt to minimize episodes of incontinence.
Nurse's Notes entries further revealed that the resident's incontinence persisted. A UTI was confirmed on 9/27/10 and the resident began antibiotic treatment on 9/29/10. The resident continued to be incontinent every day through 10/7/10.
The CNA assigned to the resident was interviewed at 10:30AM on 10/7/10. He stated that the resident has not regained urinary continence. The CNA stated that the resident wears diapers and he is always wet when the CNA goes about every two hours to change him. He stated that the resident no longer tells him if he needs to urinate and the CNA does not ask the resident if he has to void. The CNA stated that the resident is not on a schedule for toileting and he does not assist or encourage the resident to use the bathroom to urinate. He stated that it would be difficult for the resident to comply with a toileting schedule because he goes downstairs to smoke.
The unit RN was interviewed at 11:30AM on 10/7/10. She stated that the care team suspected that the resident's incontinence was most likely related to his UTI. The RN stated that the team had not attempted to identify other factors that could possibly contribute to the resident's incontinence. The RN further stated that a toileting schedule to promote continence had not been implemented for the resident because change in his routine causes him to get upset. The RN stated that other possible causes would be investigated if the resident was still incontinent after the UTI was treated.
415.12(d)(1)(2)

2000 NFPA 101 - Chapter 19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, \i Standard for Health Care Facilities .

1999 NFPA 99 Chapter 16-3.8 Gas Equipment Requirements.
16-3.8.1 Patient. Equipment shall conform to requirements for patient equipment in Chapter 8.

Chapter 8 Gas Equipment.
8-2 Nature of Hazards.
8-2.1 Fire and Explosions.
8-2.1.2 During Respiratory Therapy Administration.
8-2.1.2.1 Any mixture of breathing gases used in respiratory therapy will support combustion. In an oxygen-enriched atmosphere, materials that are combustible and flammable in air ignite more easily and burn more vigorously. Materials not normally considered to be combustible may be so in an oxygen-enriched atmosphere.

8-2.1.2.2 Combustible materials that could be found near patients who are to receive respiratory therapy include hair oils, oil-based lubricants, skin lotions, facial tissues, clothing, bed linen, tent canopies, rubber and plastic articles, gas-supply and suction tubing, ether, alcohols, and acetone.

Based on observation and interview the facility did not ensure that medical gas is protected in accordance with NFPA 99 in that an oxygen concentrator was found operating in a resident's room when not in use. In addition, the nasal cannula tubing used to deliver the oxygen was resting on combustible materials, such as pillows and bed linens.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

On 10/4/10 between 9:30 AM - 1:00PM during environmental rounds the following conditions were observed in resident room #2W5:

1. At 9:30AM, the room was unoccupied and oxygen was observed flowing freely into the environment at a rate of 2 liters per minute via nasal cannula tubing that was lying on the pillow and bed sheets. This oxygen stream was being generated by a concentrator located between the heads of both residents' beds.
2. At 10:30AM oxygen was observed flowing into the environment at 2 liters per minute via nasal cannula that was lying on top of the bed sheets. The resident was alone in the room, grooming himself. Once done with his grooming, this resident applied the nasal cannula and lay down in bed independently.
3. At 12:30PM and 1:00PM oxygen was again observed flowing freely into the environment via nasal cannula draped over a pillow and the head of the bed at a rate of 2 liters per minute. The room was unoccupied.

In an interview on 10/4/10 at 1:00 PM, the Maintenance Director stated that the oxygen
concentrator should not have been operating while not in use.

NFPA 101 (2000 edition) 19.3.2.4
NFPA 99 (1999 edition) 16-3.8.1, 8-2.1.2.1, 8-2.1.2.2
10NYCRR 711.2(a)(1)

Based on observation and interview it was determined that the facility did not ensure that the exit discharge from 1 of 3 exits located on the main level, provided a safe access to a public way in that this exit discharged out onto a surface that was uneven, partially unpaved, and prone to flooding due to weather conditions (snow, ice, and rain).

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

Findings are:

On 10/4/10 at 10:00AM during life safety rounds it was observed that the exit from the center lobby stairwell discharged out onto an uneven surface that was partially paved with bricks, deteriorating asphalt, and uneven dirt that was prone to flooding due to a ground depression. This area of discharge was approximately 50 from the public way.

In an interview on 10/4/10 at 10:10AM the Director of Maintenance concurred with this observation.

NFPA 101 (2000 edition) 19.2.1, 7.5.4.3, 3.3.61, 3.3.62, 3.3.63, 3.3.121
10NYCRR 711.2(a)(1)

The following waiver is on file with this office. A repeat waiver is granted based on previous justification by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waiver has been granted has not changed. The facility wishes the waiver to be continued.

K32
SS=B

The interior stairways at the East and West ends of the building discharge into the ground floor corridor.

NFPA 101 LSC 2000: 7.7.1
711.2(a)(1)