Riverledge Health Care and Rehabilitation Center

Based on record reviews, observations, and interviews with residents and staff during the standard survey, it was determined the facility did not ensure 1 (Resident #6) of 18 residents who were reviewed for falls, received adequate supervision to prevent accidents. Specifically, the facility did not implement changes to Resident #6's plan of care to address his continuing falls. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY OF AUGUST 21, 2009.

Resident #6 had diagnoses including senile dementia, anxiety, and a history of recurrent falls and aggressive behaviors.

Nursing notes dated June 4, 2010 documented the resident was sent to the hospital's emergency room due to weakness, falls, and continued loose stools, and the resident returned to the facility the same day with new comfort care orders by the physician per family request.

Physician's progress notes dated June 9, 2010 documented the resident had 4 falls during May 2010.

A Fall Risk Evaluation dated June 12, 2010 documented the resident was at high risk for falls due to his history of recurrent falls. The evaluation documented "the resident has been increasingly weak with gait becoming more unsteady. Has had several falls during the past month. Tabs (personal) alarm now being utilized to alert staff of any attempts to self-ambulate. Now 1 assist for transfer/ambulation."

The Minimum Data Set (MDS) assessment dated June 14, 2010 documented the resident had moderate cognitive impairment, and required assistance for all ADLs (activities of daily living) including bed mobility, transfer, ambulation, toileting, and personal hygiene. The MDS assessment documented the resident experienced periods of restlessness, his mental function varied over the course of a day, and his conditions/diseases made his cognitive, ADL, mood or behavior patterns unstable. The MDS assessment documented the resident fell in the past 30 days, and in the past 31-180 days.

An incident report dated June 14, 2010 documented at 6:15 PM a loud noise was heard and a Tabs alarm was sounding from the resident's room. The resident was found lying on his stomach. The resident sustained a 0.2 cm (centimeters) laceration to his right forehead, and a 3 cm x 2 cm ecchymosis (bruise) area around the laceration.

Nursing notes dated June 22, 2010 documented the resident's family member did not wish to initiate a wedge cushion recommended by the interdisciplinary team to reduce the risk of falls. Nursing notes documented the family member visited the resident on June 20, 2010, and witnessed him get up suddenly, and said he had to use the bathroom. The family member said although she was seated right next to the resident, she was not able to react fast enough, and he walked very quickly to the bathroom. The family member said the Tabs alarm was effective to notify staff when the resident got up and she did not want to restrain him at that time.

The resident's care plan dated June 22, 2010, which was used by the certified nurse aides (CNAs), documented the resident was alert with confusion and ambulated using a walker along with assistance from staff, and had been known to ambulate without the walker. The resident was incontinent and was to be toileted every 4 hours and PRN (as needed). The resident wore non-skid socks and was on 30 minute checks for safety.

A significant change assessment dated June 24, 2010 documented the resident required staff assistance to safely transfer and ambulate, and continued to attempt to walk unassisted which resulted in several falls with no injuries. A Tabs alarm was used to alert staff of those attempts. The resident could become frustrated with the alarm, and the Tabs alarm was not placed on him at those times.

Nursing notes dated July 6, 2010 at 12:10 AM documented the resident was heard calling out. Nursing notes documented the resident was discovered sitting on his buttocks on the floor next to his bed, legs fully extended in front of him. He said, "the floor was slippery and down I went." There was no apparent injuries at that time (July 6, 2010). At 3:30 AM, nursing notes documented the Tabs alarm was ringing, and the resident was noted ambulating out of his room, and stated he was "looking for my lawn mower." At 4:40 AM, progress notes documented the resident was heard calling out from a female resident's room. When the CNA entered the room, she observed Resident #6 slap the female resident's face. He said to the CNA, "she's in my bed." The resident was easily redirected back to his own room/bed and the Tabs alarm (which had been removed by the resident) was reapplied.

An incident report of July 17, 2010 documented at 6:40 PM, the resident was seen walking alone in the hallway and noted to have lost his balance. Staff were unable to stop him from falling. The resident hit the back of his head on the floor and sustained a small hematoma (swelling), along with a small skin tear to his left elbow, and a small abrasion between his eyebrows.

A follow-up investigation report to the resident's fall on July 17, 2010 documented on the following evening (July 18, 2010), the resident complained of left wrist pain, was unable to move his wrist, and had bruising and swelling. After evaluation by the registered nurse (RN) Supervisor, the resident was sent to the emergency room (ER) for evaluation. Information received from the ER documented the resident had a wrist fracture. The x-ray report was received by the facility on July 19, 2010, and showed no fracture. The resident's follow-up appointment with the orthopedic surgeon on July 20, 2010, documented the resident had moderate swelling of his hand and fingers with nondisplaced fracture base of the fifth metacarpal (palm).

Nursing notes dated July 19, 2010 documented the resident returned from the ER with a splint and Ace wrap in place to his left hand/wrist. The Tabs alarm was in place and he was placed on 15 minute checks.

The comprehensive care plan (CCP), last reviewed by the interdisciplinary team on July 19, 2010, documented the resident had dementia, was at risk for elopement and needed to be monitored for safety issues. The CCP documented the resident was at risk for falls due to his history of falls with injury since admission, used an assistive device, and needed staff assistance for safe transfers and ambulation. The resident made frequent attempts to walk unassisted, was incontinent, and was on comfort care.
The CCP documented the resident;
- fell on July 17, 2010 which resulted in a fracture of the left base of the fifth metacarpal (hand);
- fell on July 29, 2010, and on August 1, 2010 was placed on 15 minute checks; and
- fell in the bathroom on August 2, 1010 which resulted in no injury.
Prevention strategies included:
- 30 minute checks for safety;
- Tabs alarm-document any resistance to the alarm: If the resident refused, see care sheet for specifics;
- non-skid socks.
Follow-up with the resident's family as indicated with falls. The health care proxy (HCP) was "aware of further risk of injury from falls, but wishes for resident not to be restrained at this time."

The resident's care plan documented on July 19, 2010, bed and chair alarms were to be on at all times, and if the resident refused, staff would inform the nurse and staff would be assigned to check the resident every 15 minutes until he allowed the Tabs alarm to be applied.

Physician's telephone orders dated July 27, 2010 documented the resident was given a one time dose of 40 mg of Lasix IM (intramuscular) due to edema and shortness of breath. Another dose of Lasix (40 mg IM) could be given again in 2 hours if no diuresis (urination) occurred. Physician's telephone orders also documented the resident was to receive Lasix 40 mg PO (by mouth) QD (daily).

The resident's care plan on August 1, 2010 documented the resident was placed on 15 minute checks for safety.

Incident reports reviewed from June 2, 2010 through August 2, 2010 noted the resident fell a total of 13 times and documented:

On August 3, 2010, during the 7:00 AM - 3:00 PM shift, nursing notes documented the resident had a recent fracture (July 17, 2010). The resident told staff he was able to transfer and ambulate independently. The resident had edema on both lower legs and feet, which may have contributed to the resident's difficulty with mobility and falls. Nursing notes documented the resident received daily Lasix and the physician was aware of the resident's falls.

On August 3, 2010, during the 11:00 PM - 7:00 AM shift,nursing notes documented the resident removed his Tabs alarm twice, and was encouraged to keep it in place.

On August 4, 2010 at 3:50 PM, the resident was observed by the surveyor in his room located at the end of the corridor (last room), farthest away from the unit nurse's station. He was seated in an easy chair with a wheeled walker was next to his bed, and his Tabs alarm in place. The resident was wearing non-skid socks and a pair of sneakers were observed on the floor next to his bed. When asked by a surveyor, the resident denied having any pain in his left hand, and having had any falls.

When interviewed on August 5, 2010 at 9:30 AM, the resident's primary CNA said the resident was supposed to use his walker when he ambulated, but sometimes went to the bathroom without it. His Tabs alarm was supposed to be in place at all times. The CNA said when the resident took it off, the nurse was to notified. The CNA said the resident was on 15 minute checks and the Tabs alarm should be in place because the resident continued to fall when he ambulated. The CNA said the resident did not use the call bell, and "yelled" when he needed help. The CNA said when she was busy with other residents, it was hard to hear when the resident yelled for help. When asked by a surveyor if she could hear the resident's Tabs alarm sounding, the CNA said if she was near the unit dining room or providing care to another resident, it was hard to hear it. The CNA said the resident was checked every 15-20 minutes. Information was provided during "shift report" as to who was responsible for completing the every 15 minute checks on the resident. When asked by a surveyor how the CNA kept track of when the resident was last checked, the CNA said she looked at the clock in the unit dining room, because she did not wear a watch. When asked if she documented the every 15 minutes checks on the resident, the CNA said, "we (the CNAs) have not been asked to document this." The CNA said she thought the resident was given medication, and nursing staff was aware of this. The CNA said the resident used to be in a room that was closer to the nurse's station. The CNA said, "someone should be with him. We could do 1:1 (supervision)."

On August 5, 2010 at 11:40 AM, the resident was observed in his room seated in an easy chair. He was wearing non-skid socks and his Tabs alarm was in place. The resident's left hand was observed to be swollen, and when asked by a surveyor about it, the resident said his left hand was swollen more than the right one. "It just comes that way." The resident did not know why his left hand was swollen. When asked by a surveyor if he used his walker, the resident said, "I don't need it much. I can do OK without it." The resident denied having had any falls. Both of the resident's legs were observed to be edematous (excess fluid). The resident told a surveyor he could "walk all over the and has no trouble walking anywhere."

During a telephone interview on August 5, 2010 at 2 PM, the Medical Director (resident's primary physician was not available for interview) stated he was not familiar with the resident. A surveyor provided the medical director with information about the resident's history of falls, current status and care plan interventions that had been put in place to prevent additional falls. The Medical Director said, "I don't know if you can make him safe." The Medical Director said it should be documented by staff that the resident was being checked every 15 minutes. This was the facility's policy. The Medical Director said it should be considered to move the resident closer to the nurse's station. The Medical Director said, "I think we need to care plan (for the resident) and take it up one more notch. We will be on this by tomorrow."

When interviewed on August 5, 2010 at 2:30 PM, the RN Unit Manager stated after the resident experienced 2 more falls following his fall on July 17, 2010 which resulted in a fracture, no new interventions were put in place. The resident's family did not want any restraints implemented. When asked by a surveyor if the interdisciplinary team discussed any additional interventions other than restraints, the RN Unit Manager said there had been no discussion about moving the resident closer to the nurse's station.

In summary, the facility did not ensure the resident received adequate supervision to prevent falls after experiencing repeated falls, some with injury. The resident was not reassessed and no new interventions were put in place when it was documented the resident:
-continued to ambulate unassisted;
-did not consistently use his walker for ambulation;
-frequently removed his Tabs alarm;
-did not use his call bell;
-sometimes could not be heard from his room yelling for help, and;
-was given a diuretic which increased his urgency and frequency in using the bathroom.

10 NYCRR 415.12 (h)(2)

Based on observations and staff interviews conducted during the standard survey, the facility did not ensure both toilet rooms in the main lobby were equipped with a nurse call bell. Specifically, 2 toilet rooms adjacent to the main entrance lobby were not equipped with a nurse call bell for those residents who use the toilet room (including Residents #28 and 29). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the survey from August 3 - 6, 2010, the surveyor observed the 2 toilet rooms located near the main entrance lobby were not equipped with a nurse call bell.

At 10:00 AM on August 5, 2010, the surveyor asked the receptionist in the main lobby if residents used the toilet rooms adjacent to the lobby. The receptionist stated very few residents used these rooms. She stated she could recall seeing Resident #28 using the toilet rooms.

At 9:15 AM on August 6, 2010, a surveyor observed Resident #29 outside one of the toilet rooms, waiting for the occupant of the toilet room to leave. When the occupant of the toilet room left, Resident #29 entered the toilet room.

During an interview at 11:30 AM on August 6, 2010, the facility Administrator stated the 2 toilet rooms were never equipped with a nurse call bell.

In summary, the 2 toilet rooms adjacent to the main entrance lobby were used by residents and were not equipped with a nurse call bell.

10 NYCRR 415.29
10 NYCRR 713-1.19 (g)(2)

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the facility did not ensure 1 of 7 residents reviewed for physical restraints (Resident #25) was free from physical restraints not required to treat her medical symptoms. Specifically, the facility used a device (a gait belt) on the resident that was not designed or intended to be used as a restraint, and the device was improperly applied/positioned. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #25 had diagnoses including dementia and psychosis.

The resident's quarterly Minimum Data Set (MDS) assessment of June 1, 2010 documented the resident's cognitive skills were moderately impaired and the resident needed the assistance of one staff person with ambulation, transfers, dressing, and hygiene. The MDS also documented the resident was physically abusive, verbally abusive, resistive to care, and had fallen in the past 31-180 days.

The Physician Orders of June 8, 2010 included an order for "Gait belt when in wheelchair due to unsafe ambulation and placing self on floor multiple times, release when out of wheelchair, every 2 hours, and PRN (as needed). Leave on during meals."

The resident's Comprehensive Care Plan of June 10, 2010 documented the need of a gait belt restraint when in the wheelchair due to the resident's attempts to ambulate unassisted resulting in frequent falls.

The resident's Restraint Evaluation of June 16, 2010 documented the need of a gait belt restraint when in the wheelchair due to the resident's attempts to ambulate unassisted resulting in frequent falls.

At 2:00 PM on August 4, 2010, the resident was observed sitting in her wheelchair in the unit dining room. A gait belt (used to assist residents to ambulate) was observed positioned around her chest and buckled at the rear of the wheelchair. There was a gap between the belt and wheelchair at the back, and the belt was loose where it was positioned at the resident's chest.

At 2:15 PM on August 5, 2010, the registered nurse (RN) Unit Manager was interviewed regarding the gait belt used to restrain the resident. The RN stated the resident had a history of falls, and was able to remove a lap buddy (trunk restraint). She stated the resident's family member requested the use of a seat belt restraint to keep the resident safe, and the resident had been able to unfasten other seat belts that were trialed. She stated the use of the gait belt was an interdisciplinary team decision.

At 2:55 PM on August 5, 2010, a surveyor observed the resident with the RN Unit Manager. The gait belt was positioned across the resident's chest and buckled at the back of the wheelchair. When asked about the position of the belt, the RN stated it should have been positioned lower.

At 3:10 PM on August 5, 2010, a surveyor observed the resident with the physical therapist. The gait belt was in the same position as observed at 2:55 PM earlier that day. The therapist stated the gait belt was a restraint of "last resort," and should have been positioned lower (across the resident's lap). After repositioning the belt, the therapist said the belt was still too high. He said the gait belt was not designed for use as a restraint, and he would research other options.

During an interview with the resident's assigned certified nurse aide (CNA) at 1:00 PM on August 6, 2010, the CNA said she was shown how to position the resident's seat belt earlier the same day.

At 1:30 PM on August 6, 2010, the facility Quality Assurance (QA) Facilitator was interviewed regarding the QA committee's audits during the past 12 months. When asked if the committee did audits related to the restraints during the past 12 months, she stated the committee reviewed recliners, low beds, and lap buddies (trunk restraints). She stated the facility had not audited seat belt restraints in the past 12 months.

In summary, for Resident #25's restraint:
- the facility used a device (a gait belt) that was not designed or intended to be used as a restraint;
- the gait belt was positioned in a manner that could be uncomfortable, restrictive, and with the the possibility of the resident being able to slide underneath it, causing serious injury;
- staff did not re-assess the positioning and suitability of the gait belt until it was brought to the staff's attention; and
- direct care staff did not receive direction on how to apply the belt correctly until it was brought to the staff's attention.

10 NYCRR 415.4 (a)(2)(iv),(3)(i-iii)

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the services provided by the facility did not meet professional standards of quality for 1 of 30 sampled residents (Resident #6). Specifically, the facility did not re-evaluate the resident's optimal footwear in light of the resident's significant edema which prevented the resident from wearing his usual footwear. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #6 had diagnoses including cognitive impairment, senile dementia, anxiety, unspecified psychosis, and a history of recurrent falls and aggressive behaviors.

The Minimum Data Set (MDS) assessment dated June 14, 2010 documented the resident had moderate cognitive impairment, was able to make himself understood, and usually was able to understand others. The resident required assistance from staff for all ADLs (activities of daily living), and assistance with bed mobility, transfer, ambulation, toileting, and personal hygiene.

A pressure ulcer risk assessment (Braden Scale Plus) of June 21, 2010 determined the resident was at "high risk" of developing pressure ulcers due to moist skin, poor nutrition, and friction/shear.

At 11:45 AM on August 5, 2010, the surveyor observed the resident sitting in his chair in his room. He was wearing slipper socks on his feet and both feet were resting directly on the floor. The resident's lower legs and feet were very swollen with edema (fluid retention). At 11:55 AM, the Certified Nurse Aide (CNA) was asked about the resident's legs and feet. The CNA explained the resident had no trouble walking, but because of the swelling of his feet, the resident could no longer wear his shoes/sneakers. When requested by the surveyor, the CNA removed the resident's slipper socks. The resident had red marks on the top and sides of his toes on both feet.

At 4:20 PM on August 5, 2010, the Registered Nurse (RN) unit manager and the skin care nurse (RN) were interviewed. When asked about the red marks on the bottom of the resident's feet, the skin care nurse stated she was not sure if the red marks were totally caused by pressure. The unit manager was not aware the resident had red marks on his feet and explained the resident wore sneakers up until a week ago, but can no longer wear them because of the edema in his lower legs and feet. The skin nurse stated it would be beneficial for a physical therapist to evaluate the resident for appropriate footwear.

A note by the skin care nurse written at 4:45 PM on August 5, 2010 documented, "Both feet and lower extremities are grossly edematous, feet are cool to touch. .... At this time, with feet elevated, soles of feet, tips of toes, and top of great toes are purple to deep pink, blanches easily. Patient is no longer able to wear usual shoes because of edema. Recommend physical therapy to evaluate to identify appropriate foot wear. ... Patient is at increased risk of developing pressure ulcers."

At 10:35 AM on August 6, 2010, the resident was observed sitting in his chair in his room. He was wearing sneakers. At 11:45 AM, the resident was observed to be transported to the dining room in a wheelchair. He was wearing sneakers. At 12:30 PM, the resident was observed in the dining room eating his lunch with his sneakers on. When the unit manager was asked why the resident was wearing sneakers, she stated the resident had been wearing the sneakers for the last two hours and insisted on having them on.

In summary, for this resident at risk for skin breakdown, the facility did not re-evaluate the resident's optimal footwear in light of the resident's recent significant edema which prevented the resident from wearing his usual footwear. Continued use of the resident's tight-fitting sneakers increases the risk of skin breakdown.

10 NYCRR 415.11 (c)(3)(i)

Based on observations and staff interviews during the standard survey, the facility did not ensure a window sill was no greater than 36 inches above the floor in 1 sleeping room of this 65 bed building (building with units B, I, and J). Specifically, the window sill in Room I-2 (a respite room) is approximately 60 inches above the floor. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During previous recertification surveys, the window sill of the window in Room I-2 was observed to be approximately 60 inches above the floor. Facility staff explained that the window had to be installed at that height to clear the roof line of the newly constructed building attached to the existing building in the vicinity of Room I-2.

In summary, the window sill in Room I-2 was greater than 36 inches above the floor.

(A waiver was previously granted for this deficiency and a repeat waiver will be continued. No plan of correction is required for this item.)

10 NYCRR 711.2 (a)(1)
2000 Life Safety Code (NFPA 101) 18.3.8

Based on observations and staff interviews during the standard survey, the facility did not ensure a window sill was no greater than 36 inches above the floor in 1 sleeping room of this 65 bed building (building with units B, I, and J). Specifically, the window sill in Room I-2 (a respite room) is approximately 60 inches above the floor. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During previous recertification surveys, the window sill of the window in Room I-2 was observed to be approximately 60 inches above the floor. Facility staff explained that the window had to be installed at that height to clear the roof line of the newly constructed building attached to the existing building in the vicinity of Room I-2.

In summary, the window sill in Room I-2 was greater than 36 inches above the floor.

(A waiver was previously granted for this deficiency and a repeat waiver will be continued. No plan of correction is required for this item.)

10 NYCRR 711.2 (a)(1)
2000 Life Safety Code (NFPA 101) 18.3.8