Table of Contents
Saratoga County Maplewood Manor
Deficiency Details, Certification Survey, November 30, 2010
PFI: 0825
Regional Office: Capital District Regional Office
F156 483.10(b)(5) - (10), 483.10(b)(1): INFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: January 29, 2011
The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under ¾1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing. The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section. The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. The facility must furnish a written description of legal rights which includes: A description of the manner of protecting personal funds, under paragraph (c) of this section; A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels. A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.
Citation date: November 30, 2010
Based on record review and interview the facility did not inform two (#s 20 and 199) of seven residents reviewed, in writing, that Medicare would not pay for skilled nursing or specialized rehabilitative services and did not inform the residents why these services may not be covered during the standard recertification survey. Specifically, the demand bill notice was not provided to the resident/representative as required, no later than two days prior to termination of services. This resulted in no actual harm with a potential for more than minimal harm that was not immediate jeopardy. This was evidenced by the following:
1. Resident #20
The resident/designated representative was not notified in writing 2 days before the termination of Medicare non-coverage. A Notice of Medicare Provider Non-Coverage (demand bill) was issued to this resident's representative on 8/9/10 for termination of therapy services that ended on 8/6/10.
2. Resident #199
The resident/designated representative was not notified in writing 2 days before the termination of Medicare Non-Coverage. A Notice of Medicare Provider Non-Coverage (demand bill) was issued to this resident's representative on 9/13/10 for termination of services that ended on 9/10/10.
During an interview on 11/30/10 at 9:20 am, with the senior clerk who was responsible for sending out the demand bills, she was asked why the notices were late. She stated that sometimes that happens. Therapy may be late letting her know when they are cutting services. Sometimes things fall through the cracks, and sometimes she called the representative. She looked at the notices and stated there was no documentation that a phone call was made. She also stated that she took Fridays off in August 2010, so if she recieved a notice from therapy on a Friday then it would not be acted on until the following Monday.
On 11/30/10 at 9:33 am and 9:48 am, respectively, the Physical Therapist and Occupational Therapist were interviewed, both stated that they send notices to the senior clerk when residents are being terminated from services. Both stated they sent the notices at least 2 days prior to the termination date.
10NYCRR 415.3(g)(2)(i)
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: January 29, 2011
The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Citation date: November 30, 2010
Based on medical record review and staff interview the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, were thoroughly investigated for one (#245) of three residents reviewed during the recertification survey. Specifically, the facility did not ensure thorough investigations were completed for a resident with bruising and a pelvic fracture to determine if abuse, mistreatment or neglect occurred. This is a repeat deficiency from the standard recertification survey of 9/15/09. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by:
Resident #245
The resident was admitted to the facility on 8/7/09 with diagnoses of dementia of alzheimer's type, hypertension and gastroesophageal reflux disease. The Minimum Data Set (MDS) dated 9/29/10, assessed the resident as having short term and long term memory problems and as having moderately impaired decision making skills. It assessed that the resident required extensive one person physical assistance for transfers, ambulation, locomotion, dressing, toileting, personal hygiene, and bathing. It also documented the resident had abrasions/bruising in the last seven days.
The facility's Resident Abuse Prohibition Policy dated 10/06 documented under the investigation policy that all reports of mistreatment, neglect, or abuse of residents will be thoroughly investigated in accordance with regulation. The policy further documented that to assist in defining incidents of abuse, the following information is provided: Injuries of Unknown Origin is defined as if both of the following conditions exist: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because the extent of the injury or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time.
An Incident Report dated 7/18/10 was completed for bruising on the resident. It noted that the resident was lying in bed on her back and was noted to have a bruise on the left inner thigh measuring 7.5 centimeters by 1.5 centimeters and a hematoma to the left hand measuring 1.5 centimeters. It noted that a Certified Nursing Assistant (CNA) discovered the bruising and that it was not applicable to identify the hazard that caused the bruise or to take action to eliminate the hazard. The "Resident Version Report" attached to the Incident Report documented that the resident was unable to give a report due to her medical condition. The facility "Decision Tree to Help Determine if a Bruise Needs Further Investigation" was attached to the Incident Report and noted that the resident didn't know if the bruise was caused by another individual. It then documented that the resident did have a medical condition where bruising easily occurred, but did not identify any specific condition. There was handwritten notation that the resident had a fall on 7/5/10 (approximately two weeks prior) and had a history of bruising. The facility then documented that no investigation of the bruising was necessary. There was no documented evidence of direct staff interviews and/or staff statements having been obtained across shifts to investigate the possible cause of the bruising and to determine if there was any possibility that resident abuse and/or mistreatment may have occurred.
A nurse's note dated 7/19/10 at 1:00 am, documented that the resident had a bruise that remained dark purple in color to the left inner thigh and that the resident's left hand continued with a hard hematoma.
A nurse's note dated 9/29/10 at 12:45 am, documented that the resident presented with a large bruise to the left shin that was blue and purple in color, covering the entire front of the shin. It documented there was also a large bruise to the outer aspect of the right thigh that was dark purple with a large hard to the touch area in the middle of the bruise and swelling surrounding it.
An Incident Report dated 9/29/10, documented that the resident was being toileted when bruises were found on the front left shin and outer aspect of the right thigh. There were no documented measurements of the bruises. It was noted that two CNAs discovered the bruising. The hazard identified was noted as possibly being from a merrywalker device (an ambulation device that is a rolling walker/chair combination). The Decision Tree to Help Determine if a Bruise Needed Further Investigation attached to the Incident Report did not document that an investigation was necessary. It was handwritten on the bottom of the decision tree that a Registered Nurse Supervisor (RNS) examined the bruises and that no investigation was needed. There was no reason documented as to why the bruises did not need investigation. The Resident Version Report attached to the Incident Report documented "I'm not sure what happened." There was no documented evidence of direct staff interviews and/or staff statements having been obtained across shifts to investigate the possible cause of the bruising and to determine if there was any possibility that resident abuse and/or mistreatment may have occurred.
A nurse's note dated 10/6/10 at 8:30 am, documented that the physician was in to review an increase in the resident's right lateral thigh hematoma. It then noted that the physician ordered an x-ray of the right femur and right hip.
A Physician Visit progress note dated 10/6/10 documented that the resident had increased agitation during the evening shift. It was also noted there was a large ecchymotic (bruised) area on the right hip extending down the femur (upper leg bone) on the lateral side. The plan was for an x-ray to the right hip to be done.
The x-ray result dated 10/6/10, documented that there was a non-displaced fracture of the inferior pubic ramus (pelvis) on the right side.
There was no incident report and no investigation completed by the facility for this right pelvic fracture of unknown origin. There was no documented evidence of staff interviews and/or staff statements having been obtained across shifts to investigate the possible cause of the fracture and to determine if there was any possibility that resident abuse and/or mistreatment may have occurred.
A nurse's note dated 11/19/10 at 9:20 pm, documented that staff noted a golf ball size hematoma on the right upper extremity that was found during hour of sleep care on the tricep area (upper arm). It documented that the resident was unable to state the origin of the injury.
An Incident Report dated 11/19/10, documented that the resident had a golf ball size hematoma on the right tricep area. It was noted that the resident was on the toilet and the hematoma was found during care by a CNA. The hazard identified was increased restlessness and that the resident having a history of fragile skin and bruising. It then noted that a decision tree was completed, however, the Decision Tree to Help Determine if a Bruise Needs Further Investigation was in fact not completed and there was no decision documented as to whether an investigation into the cause of the bruise was necessary. The Resident Version Report attached to the Incident Report documented that the resident denied that the area was caused by another individual, but was unable to articulate the origin of the bruising and swelling.
A nurse's note dated 11/24/10 at 1:15 am, documented that the resident was asleep in a recliner and had sustained multiple ecchymotic areas to her lower extremities. It noted that the resident had a history of ecchymosis and that the resident spent awake time in her merrywalker.
An Incident Report dated 11/24/10 noted that the resident had multiple bruises on both lower extremities. It was documented that the resident had bruises to the right lower leg, inside right calf, near the right ankle, inside the right thigh, on the right calf, on the left hip, on the left lower hip, above the left ankle, on the left outer thigh, on the left outer calf, on the left calf, and behind the left knee. There were no measurements of the bruises documented on the incident report. It was documented that the resident was in her recliner and that the CNA discovered the bruises. The hazard identified was that the bruises were probably from a merrywalker device. The Resident Version Report attached to the Incident Report documented that the resident was unable to give a report due to her medical condition. The Decision Tree to Help Determine if a Bruise Needs Further Investigation attached to the incident report noted that the resident did not know if the bruise was caused by another individual and that the resident had a merrywalker that might have caused the bruising. It was then documented that investigation of the bruising was not necessary but there was no reason documented why no investigation was needed. There was no documented evidence of direct staff interviews and/or staff statements having been obtained across shifts to investigate the possible cause of the bruising and to determine if there was any possibility that resident abuse and/or mistreatment may have occurred.
During an interview on 11/29/10 at 2:15 pm, with the the day shift RNS who visually observed the resident's 9/29/10 bruising, stated that she was advised by the Director of Nursing (DON) and the Administrator to take a look at the resident's noted bruising during morning rounds. She explained that when doing rounds, she did not complete a formal nursing assessment of the bruising, but rather just did a visual of the bruising. She stated it was her judgment that the bruising was not as large as it had been described on the incident report and that it did not appear suspicious of abuse. She stated that this resident was always with different stages of bruising and that it was her assumption that the 9/29/10 bruising was likely from the merrywalker device. She stated that she herself had in the past observed the resident in the merrywalker device, leaning in it and being erratic with it. She stated that she never wrote a statement about her observation and that she just discussed her personal observation with the DON and the Administrator after having completed rounds. She did not believe any other staff statements were obtained.
During an interview on 11/30/10 at 8:20 am with the DON, she stated that the facility typically left it up to the nursing supervisors to look at resident bruising and assess if the bruising appeared suspicious of abuse. She stated that in relation to the 9/29/10 bruising on this resident, the supervisor who observed the bruise, did not feel it was suspicious because the resident had a history of frequent bruising when in the merrywalker device. She stated the facility typically did not question staff across shifts for all bruising because they felt it had been okay to rely on a Registered Nurse assessment and their knowledge of the resident bruising to determine if it was suspicious for abuse. She stated that if a Registered Nurse did not feel a bruise was suspicious for abuse, based on his/her judgment, then no investigation would be necessary. She stated she believed that the nursing staff was following the facility policy for when to conduct investigations for abuse, but stated that maybe the facility could revise their policy by specifying when investigations should be initiated based on size and number of bruises noted. After discussion of the location, extent, and number of bruises that this resident presented with over time, she stated that she now understood that maybe they should and could have gone further with investigation. She stated that the facility did not investigate the resident's bruising because the staff at the facility just knew this resident and her history. She stated the facility had not done an investigation of the resident's pelvic fracture, because she was told by someone that the age of the fracture was undetermined. She stated that she did not know where this information was documented and had no other explanation as to why the resident's pelvic fracture had not been investigated.
During an interview on 11/30/10 at 9:30 am with the Administrator, she stated that when bruises were identified, an incident report would be completed and a facility decision tree would be utilized to determine if a bruise was suspicious for abuse and if an investigation was necessary. She stated that the facility would decide to do further investigation of bruising, if the resident was unable to report how it occurred and if there were several large bruises or bruising in suspicious areas like on the inner thighs or on the arms. She stated that the facility did not do an investigation on this resident's pelvic fracture, because she thought the age of the fracture was unable to be determined. She stated that she didn't remember where the indeterminate age was noted, but thought that the day supervisor told her this. She stated that in cases of fractures with undetermined age of origin, the facility generally looked at documentation and paperwork to make a determination of cause. Upon discussion of this resident's noted bruising and fracture, she stated that the facility could have done a better job investigating to determine the possible cause and to rule out potential abuse and/or mistreatment of the resident. When asked if she believed that this resident was at risk for abuse, she stated, yes and then stated that her belief was that every resident in a nursing home facility was at risk for abuse.
The x-ray report dated 10/6/2010, did not identify that the pelvic fracture was of indeterminate time and the facility was unable to provide documentation of such.
10NYCRR 415.4 (b)(1)(ii)
Z560 713-1: STANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME
Scope: Widespread
Severity: Potential for no more than Minimal Harm
Corrected Date: January 29, 2011
Citation date: November 30, 2010
Based on observation and staff interview, it was determined that the facility did not comply with Title 10 of the New York State Code of Rules and Regulations, during the standard recertification survey. 10NYCRR section 713-1.19(d)(2) requires that resident room night lights be operable by a switch at the entrance to the room. Specifically, the night-lights on 4 of 6 residential units could not be controlled with a switch in the resident's room. This resulted in the potential for minimal harm. This was evidenced as follows:
During a tour of the A-1 residential unit annex corridor on 11/29/2010 at 1:45 pm, it was revealed that the night lights could not be controlled at the entrance or anywhere in residential room A-132.
The maintenance mechanic was interviewed on 11/29/2010 at 1:45 pm, as survey observations were noted and stated that all night lights on the A-1 residential unit annex, B-2 residential unit annex, and the two residential units on the third floor were controlled only at the nurse's station.
10NYCRR 713-1.19(d)(2)
K66 NFPA 101: SMOKING REGULATIONS
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: January 29, 2011
Smoking regulations are adopted and include no less than the following provisions: (1) Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area is posted with signs that read NO SMOKING or with the international symbol for no smoking. (2) Smoking by patients classified as not responsible is prohibited, except when under direct supervision. (3) Ashtrays of noncombustible material and safe design are provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available to all areas where smoking is permitted. 19.7.4
Citation date: November 30, 2010
Based on observation, staff interview and record review, it was determined that the facility did not adhere to safe smoking practices, during the standard recertification survey. 2000 NFPA 101 Life Safety Code Section 19.7.4 requires that metal containers with self closing cover devices, into which ashtrays can be emptied shall be provided in all smoking areas. Specifically, the employee smoking area did not have a metal container into which ashtrays could be emptied. Additionally, cigarette butts and ashes were found in the same receptacle as paper waste and cigarette butts littered the ground in this area. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows:
The employee smoking area was inspected on 11/29/2010 at 11:40 am, cigarette butts were found in the same receptacle as paper waste, a metal container with a self closing lid into which ashtrays can be emptied was not provided, and cigarette butts littered the ground.
A maintenance worker was interviewed on 11/29/2010 at 11:40, concurrent with survey observations, and stated that a metal container with a self closing lid into which ashtrays could be emptied, was not provided for the employee smoking area.
The facility's smoking policy was reviewed on 11/29/2010 and documented that employees were permitted to smoke in the designated areas only.
2000 NFPA 101 19.7.4 (d); 1997 NFPA 101 13-7.4 (d); 10NYCRR 415.29(a)(2), 711.2