Steuben County Infirmary

Based on observations made during the standard survey, it was determined that the facility did not ensure that corridors were equipped with firmly secured handrails on each side. The issue was related to resident use corridors where handrails were missing from the corridor walls. This affected sections of three (ground, first, second) of three resident use floors, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

On 10/14/10 at approximately 9:30 am, the sections of corridor walls of the glass-walled stairwell were observed to lack hand rails. This was observed on the ground, first, and second levels, and each section was approximately 10 feet long.

[10NYCRR 415.29(a)(1), 711.5 (k)(1)]

Based on staff interviews and record reviews, it was determined that for three of three residents reviewed for injuries of unknown origin, the facility did not thoroughly investigate bruises of unknown origin to rule out resident abuse, neglect, or mistreatment. This affected Residents #2, #8, and #10, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

The facility's policy entitled, "Unexplained Bruises," dated October 2000, revealed that all unknown bruises would be reviewed carefully by staff to determine further preventative measures. In addition, on the Resident Skin Injury Report form, dated September 2008, staff caring for the resident on the previous two shifts were expected to write a statement regarding the skin issue identified.

Skin injury reports for three residents who had bruises of unknown origin were reviewed while reviewing the facility's Abuse Protocol. The following concerns were identified during this review.

1. Resident #2 has diagnoses including mental retardation. The Minimum Data Set (MDS) Assessment, dated 8/3/10, revealed that the resident's cognitive skills for decision making are severely impaired and that he requires total assistance with activities of daily living. A resident skin injury report, dated 4/4/10, revealed the resident had a blackened area on his scrotum. The only statement was written on 4/4/10 by Certified Nursing Assistant (CNA) #1 who found the blackened area.

2. Resident #8 has diagnoses including depression. The MDS Assessment, dated 4/9/10, recorded that the resident's cognitive skills for daily decision making were moderately impaired, having difficulty making decisions in new situations. A resident skin injury report, dated 8/16/10, indicated a 4.5 x 4.5 centimeter (cm) bruise on the right lower buttock. The only statement provided was written by the CNA who discovered the bruise on 8/16/10.

3. Resident #10 had diagnoses including quadriplegia. The MDS Assessment, dated 9/4/10, recorded that the resident's cognitive skills for daily decision making are intact and that the resident needs total assistance with all activities of daily living. A resident skin injury report, dated 6/13/10, revealed a 3.6 x 0.4 cm bruise on the resident's left buttock. The resident was unaware of the bruise. The only statement was written by the CNA who discovered the bruise on 6/13/10.

The facility did not have completed investigations for the injuries identified above for Residents #2, #8, and #10.

When interviewed on 10/15/10 at 9:35 a.m., the Director of Nursing stated the investigations should have included interviews from employees on the previous 48 hours. She added that she knew there were problems with the investigations and is currently working on resolving the problems.

[10 NYCRR 415.4(b)(3)]

Based on record reviews and staff interviews, it was determined that the facility did not provide evidence that the Pre-Admission Screening and Resident Review (PASRR) was completed for five of nineteen residents reviewed for PASRR. The issues involved incomplete, inaccurate, or missing PASRRs. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #1, #2, #11, #14, and #19, and is evidenced by, but not limited to, the following:

1. Resident #1 has diagnoses including traumatic brain injury, personality change disorder, and depression. A 12/24/09 Application for involuntary admission on a medical certification form revealed that the resident had exhibited escalating aggressive, violent behavior placing residents and staff at risk for physical injury. A 12/24/09 progress note revealed that the resident exhibited unpredictable and intimidating behavior patterns towards staff and residents, which resulted in a staff member being injured. Attempts at redirection were not successful and eminent danger was present. The resident was sent to the hospital. A progress note, dated 1/4/10, revealed that on 12/29/09 the resident was involuntarily transferred to an inpatient psychiatric facility from the hospital. The resident was readmitted to the facility on 1/15/10 with diagnoses including depression and personality change secondary to traumatic brain injury. There was no new PASRR form available.

When interviewed on 10/13/10 at 12:55 p.m., the Assistant Administrator stated that the facility did ask the inpatient psychiatric center if a new PASRR needed to be completed and was told no as the resident had a Medicaid bed-hold at the facility. The Assistant Administrator stated the facility should have completed a new PASRR for the resident due to the new diagnosis of mental illness.

2. Resident #2 has diagnoses including profound mental retardation and was initially admitted to the facility on 10/8/08. The initial history and physical, dated 11/17/08, revealed that the resident was discharged to his group home on 10/20/08. The resident was hospitalized and readmitted to the facility on 11/17/08 for possible rehabilitation and, because of a feeding tube, will remain at the facility for long term care. The PASRR, dated 11/6/08, and the Level II determination, dated 11/10/08, indicated approval of the resident's short term stay in the skilled nursing facility. A 1/12/09 progress note revealed that a care conference was held with the resident, and the Association for Retarded Citizens (ARC) would officially discharge him from ARC services. He would remain at the facility permanently. A new PASRR form was not completed when the resident's status changed to long term care.

When interviewed on 10/13/10 at 12:15 p.m. and on 10/14/10 at 11:30 a.m., the Assistant Admininistrator stated that she was certain that the facility did not complete a new PASRR when Resident #2 became long term care.

3. Resident #11 was admitted to the facility on 6/7/10 with diagnoses including depression. The PASRR form was not completed. The form had no date or signature by a certified screener.

When interviewed on 10/13/10 at 2:30 p.m., the Assistant Administrator stated that the facility does not have a certified screener in house. She added that the facility calls a consultant, who is a certified screener, to come into the facility to complete the PASRRs as needed.

[10 NYCRR 415.11(e)]

Based on staff interviews and record reviews, it was determined that for three of seven residents observed for medication pass on one of three units reviewed for professional standards, the facility did not provide services that met professional standards of quality. Issues included lack of timely administration of medications for Residents #9, #10, and #22. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy and is evidenced by, but not limited to, the following:

1. Resident #22 has diagnoses including congestive heart failure, manic behaviors, and hypertension. The October 2010 Medication Administration Record (MAR) revealed that for the 9:00 a.m. medication pass, the resident should receive nine different medications. This included Abilify for manic behaviors, Lasix for fluid retention, and Revatio for severe hypertension. A physician's order, dated 10/14/10 at 11:30 a.m., included to hold the 1:00 p.m. dose of Revatio.

During an observation on 10/14/10 at 11:40 a.m., the Nurse Manager (NM) was giving medications to this resident. In interviews that day at 12:30 p.m. with the NM and at 3:30 p.m. with the Nurse Practitioner (NP), both said that the resident's 1:00 p.m. dose of Revatio was held because he did not receive his 9:00 a.m. dose until 11:40 a.m. that morning. At 3:35 p.m. that day, the NM said that the facility would consider this instance a medication error.

2. Resident #9 has diagnoses including dementia with behaviors and diabetes. The October 2010 MAR revealed that the resident should receive Metformin (Glucophage - diabetes medication) at 9:00 a.m. and 12:00 p.m. daily. The MAR for the 12:00 p.m. dose of this resident's Metformin was not signed off as administered on 10/12/10 by 1:15 p.m.

When interviewed on 10/12/10 at 1:30 p.m., Licensed Practical Nurse (LPN) #1 said the resident had not received her 12:00 p.m. Metformin and that she was called away to do something else and did not get to it on time. She said that she often works alone and that she usually finishes medication pass around 10:00 a.m.

Observations, interviews, and record reviews conducted on 10/14/10 revealed that:

a) At 11:10 a.m., LPN #2 administered the resident's 9:00 a.m. medications including the Metformin.

b) A progress note written by a Registered Nurse revealed that the resident's 9:00 a.m. dose of Metformin was given late and that the NP said to give the 12:00 p.m. Metformin as ordered.

c) At 12:30 p.m. and 3:30 p.m., the NM said that medications should be passed one hour before or after the time ordered. She said that the LPNs normally start the medication pass at 7:30 a.m. and finish by 9:30 to 10:00 a.m. The facility considers a late medication administration a medication error. The NM reported that at least six residents received medications late that day.

d) At 3:00 p.m., LPN #2 stated that when she is working with another nurse she finishes the medication pass at 10:00 a.m. to 10:15 a.m. and that when she works alone it takes until 11:00 a.m. to 11:30 a.m.

e) At 4:00 p.m., the Director of Nursing said that if medications are administered late it is considered a medication error.

3. Resident #10 has diagnoses including gastroparesis (delay in stomach emptying). The October 2010 physician orders included Reglan (an anti nausea medication) 10 milligrams (mg) two tablets before meals and at bedtime. The October 2010 MAR revealed that this medication was scheduled to be given at 7:30 a.m.

On 10/13/10 at 8:00 a.m., the resident was observed receiving Reglan 20 mg while eating breakfast. In an interview on 10/13/10 immediately after administering the Reglan 20 mg, the LPN stated that the day shift gives the 7:30 a.m medications. In an interview at 9:15 a.m., the NP stated that the Reglan should be given before meals as ordered.

During an interview on 10/14/10 at 3:35 p.m., the NM stated that the facility would consider Reglan given with breakfast a medication error.

The facility's policy entitled, "Administration of Medications," updated October 2009, revealed that all medication should be administered at the time ordered within an acceptable time range of one hour before or after the scheduled medication delivery time.

The Nursing 2010 Drug Handbook and the Physician's Desk Reference 2010, both used as resources in the facility, indicate that Reglan should be taken 30 minutes before meals.

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

Based on record reviews and staff interviews, it was determined that for two of two residents reviewed for demand bills, the facility did not have a consistent process in place to notify Medicare beneficiaries of his/her potential liability for payment of noncovered services when the limitation of liability applies. The issue is that the facility did not issue Advanced Beneficiary Notices or Denial Letters to residents (Residents #25 and #26) who continued to reside in the facility receiving custodial care after the facility had determined that Medicare would no longer pay for skilled services and did not provide Advanced Beneficiary Notices to the resident's beneficiaries. This resulted in a pattern of no actual harm with potential for minimal harm, and is evidenced by the following:

1. Record review for Resident #25 revealed that the resident was discontinued from Medicare Part A services effective 1/13/10. The resident was issued a Notice of Medicare Provider Non-Coverage letter on 1/11/10 and continued to reside in the facility receiving custodial care until she expired on 1/23/10. There was no evidence of an Advanced Beneficiary or denial letter given to the resident or legal representative informing them of their potential liability for payment.

2. Record review for Resident #26 revealed that the resident was discontinued from Medicare Part A services on 6/21/10. The resident received a Notice of Medicare Provider Non-Coverage letter on 6/18/10. The resident continued to reside in the facility receiving custodial care until 7/10/10 when she was discharged to the hospital. There was no evidence of an Advanced Beneficiary or denial letter given to the resident or their representative informing them of their potential liability for payment.

When interviewed on 10/15/10 at 10:15 a.m., the Minimum Data Set Assessment Coordinator stated that she did not know that she had to give the Advanced Beneficiary Notice in addition to the Notice of Medicare Provider Non-Coverage letter to the resident or their representative when their coverage was terminated.

[10 NYCRR 415.3(g)(2)(i)]

Based on observations conducted during the Life Safety Code Survey, it was determined that the facility did not maintain exit paths in a readily accessible manner at all times. The issue was related to doors that open into exit paths and obstruct the resulting width of these exit paths. This affected one (Lamoka) of three resident units and one (first) of three levels inside the glass-walled stairwell, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

The 2000 edition of NFPA 101, Life Safety Code, requires that during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.

1. On 10/13/10 at approximately 9:10 a.m., the doors to the linen closets on the Lamoka unit were examined. These two closets are equipped with two doors each that open outward into the exit corridor. When fully opened, each door opens to approximately 90 degrees. In this fully opened position, each door obstructs this 8 feet wide corridor by approximately 37 inches. As stated above, when fully open, these doors are allowed to project into this corridor only 7 inches, not 37 inches.

2. On 10/14/10 at approximately 9:30 a.m., the stairwell door of the glass-walled stairwell at the first floor level was examined. This door opens in the direction of egress from the first floor level into the stairwell. During its swing, this door passes the stair newel post, leaving a clearance of approximately 16 inches. The required width of this stairwell is 48 inches. Therefore, one-half of the required width is 24 inches. This door swing exceeds the requirement by 6 inches.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 18.2.1, 7-2.1.4.4; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 12-2.1, 5-2.1.4.4]

Based on observations and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not provide decorations that were flame-retardant. This affected one (Keuka) of three resident units, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

On 10/12/10 from approximately 2:20 p.m. to 3:20 p.m., the following observations were made on the Keuka unit;

1. In the lounge near the nurses' station, artificial spider webbing was stretched across the ceiling, extending approximately 12 feet x 18 feet.

2. In this same lounge, a fabric, inflated ghost decoration approximately 4 feet tall was standing on the floor.

3. In the corridor across from the nurses' station, sections of black "cheesecloth-like" material were hanging from the ceiling. One section was approximately 10 feet x 2 feet and two sections were approximately 8 feet x 2 feet.

4. The door of the Medication room in the nurses' station had a plastic poster mounted on it that was approximately 3 feet x 5 feet.

5. In the corridor outside Room #153, a fabric, inflated black cat decoration approximately 3.5 feet tall was standing on the floor.

6. On the door of the Nurse Practitioner's office, a decoration involving dangling, black cheesecloth was hanging.

7. At the charting station, a section of black "cheesecloth-like" material was hanging from the ceiling. This was approximately 12 feet x 2 feet.

8. In the library, a fabric, inflated pumpkin and ghost decoration approximately 4.5 feet tall was standing on the floor.

In an interview with the Building Supervisor at this time, he said that documentation relating to these decorations being flame-retardant was not available.

The 2000 edition of NFPA 101, Life Safety Code prohibits combustible decorations in nursing homes unless they are flame-retardant.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 18.7.5.4; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 12-7.5.4]