Momentum at South Bay for Rehabilitation and Nursing

Based upon observations, staff interviews and record reviews, the facility did not ensure there were sufficient nursing staffing levels to maintain the highest practicable level of well-being of each resident. Specifically, there were complaints that meals were not served to residents in a timely manner (10 of 10 residents in attendance at the group meeting) and allegations that call bells were not answered in a timely manner for residents who require assistance with personal hygiene, toileting, and bathing. This was evident on 4 of 4 nursing units. This resulted in no actual harm with the potential for more than minimal harm.

The findings include but are not limited to:

A Resident Council Meeting held on 6/11/10 at 1:15 PM revealed that 10 out of 10 alert and lucid residents complained of short staffing for all of the nursing units, more on the weekends and during the 3 PM to 11 PM shift and the 11 PM to the 7 AM shift. They stated that because of the short staffing, meals have been served cold and they received their medications late. Call bells were not answered in a timely manner and as a result residents did not receive assistance with personal hygiene, toileting and bathing. They also complained that showers were not provided as planned (twice weekly) because of short staffing.

Review of the 5/31/10 resident council minutes revealed that there were at minimum 33 residents in attendance who complained of hot foods served cold and call bells not answered timely.

On 6/14/10 at 2:45 PM during a confidential interview, an alert and lucid resident stated that there was a severe shortage of nursing staff during the weekend. He stated that staff were taking as long as one hour to respond to call bells. He stated he did not receive the assistance he needed to be dressed and had to dress himself without staff assistance. The resident last MDS assessment documented he had no cognitive impairment, no behavior problem and no memory problems.

On 6/15/10 at 11:00 AM an alert and lucid resident stated that on 6/13/10 during the evening shift, she was forced to wait 45 minutes for someone to respond to her call bell. She further stated that due to the delay in response time she soiled her pants. The resident stated that this was very embarrassing for her. The resident further stated that there are multiple occasion when she has had to wait more than thirty minutes for someone to respond to her call bell.

A review of the staff schedules on 6/12/10 revealed on the 7-3 PM shift there were 7 Licensed Nurses and 15 Certified Nurse Assistants (CNA), 3-11 PM shifts 6 licensed nurses and 12 CNA, 11 PM 7 AM 4 licensed nurses and 8 CNA to provide care for 160 residents. On 6/13/10 the 7-3 PM shift there were 8 Licensed Nurses and 13 Certified Nurse Assistants (CNA), 3-11 PM shifts 6 licensed nurses and 10.5 CNA, 11 PM 7 AM shift, 4 licensed nurses and 9 CNA to provide care for 148 residents.

The Director of Nursing Services was interviewed on 6/15/10 at 12:00 PM and stated there were staff members who called in over the weekend. Substitutes staff were not available and that resulted in limited numbers of personnel. She was not aware of any adverse resident consequences as a result of the limited staffing. The DNS also stated that the facility has a policy for minimum staffing which is :
The 7 AM - 3 PM shift is: 4 licensed nurses and 8 CNA'S.
The 3 PM-11 PM shift is: 3 licensed nurses and 6 CNA'S.
The 11 PM-7 AM shift is : 3 licensed nurses and 3 CNA'S.

415.13(a)(1)

Based on record review and staff interviews during a standard survey, the facility did not ensure that the residents receive services in the facility with reasonable accommodations of individual needs and preferences. This was observed for two residents (#5 and 20) in a total of 24 sampled residents. Specifically, the facility did not provide the necessary toileting equipment for Resident #5, and a hemi-walker (assistive device for walking) for Resident #20. This resulted in no actual harm with a potential for more than minimal harm which is not an immediate jeopardy.

The findings are:

1) Resident #5 has diagnoses including Bilateral Below Knee Amputation (BKA), Peptic Ulcer Disease and Expressive Aphasia (difficulty in talking).

The resident had resided in the facility with a left below knee amputation and was re admitted with a right below knee amputation on 3/24/10.

A Minimum Data Set (MDS) Assessment dated 4/2010 documented that the resident had impaired memory and moderately impaired cognition.

A Comprehensive Care Plan (CCP) dated 6/2010 documented that the resident required 2 persons extensive assistance; to pull up in bed, and to transfer with a slide board.

The CCP for Bowel and Bladder Continence initiated on 3/18/10 and updated through 6/9/10 documented that the resident was usually continent of bladder and occasionally incontinent of bowel due to recent hospitalization. The CCP documented that briefs or pads were in use and to assist with urinal at night.

The Nursing Assessment Care Plan and Accountability Record dated 2/2010 documented that the resident was continent of bowel and bladder and required assistance with urinal at night. The Accountability Records dated 3/26/2010, April, May, June 2010 documented the resident to be incontinent of bowel and bladder. The Accountability Record dated 3/26/2010 documented to use diaper/pad and Hoyer back to bed for bed pan use. The April, May, June 2010 Accountability Record documented to use diaper/pad and slide board back to bed for bed pan use.

The Certified Nursing Assistant (CNA) assigned to the resident was interviewed on 6/11/10 at 10:30 AM. The CNA stated that she was assigned to care for the resident for 11:00 PM- 7:00 AM shift and is currently caring for the resident during 7:00 AM-3:00 PM shift. She stated that the resident is continent of urine and uses a urinal. She stated that the resident is also continent of bowel and knows when to go and has a bowel movement only once daily in the morning around 9:00 AM. The CNA stated that the resident has his bowel movement in bed, calls her after having a bowel movement and stays on his side until she goes and cleans him.

The Licensed Practical Rehabilitation Nurse (LPN)was interviewed on 6/11/10 at 9:30 AM. The LPN stated that the resident was confused and incontinent of Bowel and Bladder and is unable to tell you due to expressive aphasia. The LPN stated that the resident is a candidate for a toileting program but requires an armless commode to facilitate his slide board transfer. She stated that the armless commode is not available in the facility. Additionally the LPN stated that the requirement for armless commode has been brought to the administration's attention by Nursing.

2) Resident #20 has diagnoses including Right Hemiplegia and Status Post Myocardial Infarction.

A Comprehensive Care Plan (CCP) for cognition dated 3/5/10 documented that the resident is alert and oriented times three and has intact memory.

The CCP for self care deficit dated 3/5/10 and updated on 5/19/10 documented that the resident used wheel chair for mobility; will ambulate at least three times a week with a hemi walker (assistive device for walking) as tolerated and to encourage ambulation with 1 assist and hemi walker daily. It was also documented that the resident ambulates with a hemi walker independently in room as tolerated and on hallways twice a week or less.

The Nursing Assessment Care Plan and Accountability Record (NACAR) for January and February 2010 documented Ambulation as independent with a hemi walker.

A Physical Therapy (PT) Evaluation dated 4/2/09 documented independent ambulation with a Quad cane (ambulation assistance device) 10-20 feet, the goal was to maintain status. A PT Screen dated 2/16/10 documented that the resident walked only a few steps with Quad cane and that the resident's status was unchanged.

The NACAR for March, May and June 2010 documented Ambulation as independent/limited assist of one with a hemi-walker and to encourage ambulation. The NACAR for April 2010 could not be located.

The NACAR did not document the ambulation performed by the resident during these months. There was no other documentation related to the resident's actual ambulation performance.

The resident was interviewed in his room on 6/15/10 at 8:30 AM. He was seated in a wheel chair and stated that he cannot use his right arm and foot but is relatively independent. The resident further stated that he used to ambulate when his personal Quad cane which was taken away from him. He stated that he still walks a little in his room with a regular cane. The resident was observed to have a regular cane in his possession. He stated that he told the unit Nurses and the Physical Therapist about loosing his personal Quad cane.

The resident's assigned 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) was interviewed on 6/15/10 at 9:30 AM. The CNA stated that the resident does everything for himself. She stated that he is already in wheel chair from the night shift and she has never seen him ambulate in the last 6 months nor has she seen any of his ambulation devices. She stated that the resident refuses to ambulate and that she has reported this to the Charge Nurse. When asked which device she would have given him to ambulate she stated that if the resident had agreed to ambulate she would have asked the Charge Nurse, who would have then called the PT Department for the device.

The PT was interviewed on 6/15/10 at 10:00 AM. ans she stated that the resident refuses to walk. She also stated that the resident recently told her that his Quad cane was taken out of his room. She stated that she brought two Quad canes to show the resident, but the resident stated these were not like the Quad canes he had before and did not want it. She stated that he only wanted the Quad cane he had before.

She then proceeded to bring a hemi walker and showed it to the resident. The resident stated that this Quad cane was like the one he had lost and he readily agreed to ambulate with it. He stated that he thought this was a Quad cane and did not know it was a hemi walker. The resident was observed to ambulate 10 feet with the hemi-walker.

The PT could not explain the discrepancy in the ambulation device documentation in the resident's CCP and Accountability records and in the PT assessments. She stated that the PT ambulation assessment was completed using the Quad cane and that she did not complete the care plans. The PT stated that had she been aware of the resident's preference for a hemi walker she would have ordered one for him. The PT stated that there are three options of ambulation devices for a hemiplegic person and that PT assessed the resident with only a Quad cane. She could not explain why no further assessments or recommendations were made after the PT screen dated 2/16/10, during which the resident walked only a few steps with the Quad cane.

The unit Charge Registered Nurse was not available for interview.

The Director of Nursing was interviewed on 6/15/10 at 1:30 PM. She stated that there should have been nursing documentation regarding the resident's refusal to ambulate. She further stated that the PT and Nursing should have checked for the availability of the correct device and accuracy of assessments and documentation during the CCP meetings.

415.5(e)(1)

Based on observations, record review and staff interviews, it was determined that one of 7 residents reviewed during the standard survey for decline in activities of daily living did not receive the necessary services to prevent a decline in ambulation. Specifically the facility did not ensure that Resident #9 who was ambulatory on admission was evaluated after a significant change in ambulatory status. The resident's ambulation ability declined from January 2009 to March 2010. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy.

The finding is:

Resident #9 has diagnoses including Renal Failure, cerebral Vascular Disease and Chronic Obstructive Pulmonary Disease.

The Minimum Data Set (MDS) Assessment dated 1/2/10 documented Resident #9's Activities of Daily Living (ADL) status as limited assist in transfer and ambulation.

The MDS assessment dated 3/26/10 documented a change in ADLs requiring two person assist for transfer and non-ambulatory .

The Nursing Assessment/Care Plan and Accountability Record dated 1/6/10 and 2/10 documented Resident #9's ambulatory status as supervised with a rolling walker.

During an interview with the (LPN) Licensed Practical Nurse on 6/14/10 at 11:00 AM, she stated that she should have documented the significant change in the Nursing Progress notes.

The Physical Therapy Screening dated 2/11/10 documented specific instructions that the "patient should be encouraged to ambulate with walker to all destinations...".

The Nursing and Rehabilitation Communications form dated 3/22/10 documented "patient is no longer ambulatory, may transfer with assist of one..".

The physician note dated 4/19/10 did not include that the resident had declined functionally and was not ambulating.

During interview on 6/14/10 at 1:00 PM with the Physical Therapist, she stated she was unaware of the significant change MDS that was completed on 3/26/10. She further stated had she been made aware, she would have completed a full assessment of Resident #9.

During interview with 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) on 6/14/10 at 10:30 AM who provided ADL care to Resident #9, she stated that the resident is no longer able to ambulate or stand and is transferred using a mechanical lift.

During interview on 6/15/10 at 2:00 PM with Resident #9's physician, he stated that he was aware of the resident's decline in ambulation and the resident would have benefited from restorative therapy.

415.12(a)(1)(i-v)

Based on observation and staff interviews, it was determined that the facility did not ensure that housekeeping and maintenance services maintained a sanitary, orderly, and comfortable interior on one of two (2nd) floors. Specifically, a loosely hanging ceiling tile was observed over one resident's bed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #28's family was interviewed on 6/15/10 at 3:30 PM and stated that the ceiling tile in the resident's room was falling apart and this was reported to the facility on numerous occasions. The resident's room was observed at 3:45 PM on 6/15/10 with (3) three loose ceiling tiles near the curtain track above the resident's bed. A cluster of dust material was observed in between the loose ceiling tiles.

In an interview on the same day at 3:50 PM, the Director of Environmental services stated that he routinely checks the rooms and was not aware of the loose ceiling tiles in Resident #28's room.

NYCRR 415.5(h)(2)

Based on record review and staff interviews during a standard survey the facility did not ensure that services provided or arranged by the facility are provided in accordance with each resident's written plan of care. This was noted for one resident (#10) in a total of 24 sampled residents. Specifically, there was no documented evidence that a plan for the resident's dental procedure was carried out.
This resulted in no actual harm with a potential for more than minimal harm which is not an immediate jeopardy.

The finding is:

Resident #10 has diagnoses including Syncope and Dementia.

A Minimum Data Set (MDS) Assessment dated 4/28/10 documented that the resident's cognition was moderately impaired and that the resident had memory problems.

Review of the resident's medical record revealed that the resident was seen by the Dentist on 1/1/10 who documented a need for a filling of decayed upper right central incisor.

A medical clearance for the filling was obtained on 1/15/10.

The medical record including Comprehensive Care Plans and medical and nursing progress notes from January through June 2010 was reviewed. There was no documentation with regards to the planned dental procedure completion.

In an interview with the unit Registered Charge Nurse on 6/11/10 at 1:45 AM she stated that the resident had refused to go for the procedure. The LPN stated that she did not recall if the family and the Social worker were made aware of the resident's refusal. The LPN stated that the resident's refusal should have been documented in the medical record.

The Social Worker was interviewed on 6/11/10 at 1:45 PM and stated that if she had known about the resident's refusal, she would have contacted the resident's family to see if they could be present when the Dentist came in.

415.11(c)(3)(ii)

Based on observation and staff interview the facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full use in the case of fire or other emergency. This was evidenced by a flooded egress discharge (public way).

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

The Findings are:

During life safety inspection on 06/10/10 the following was observed throughout the survey between 9:00am and 11:00am:

1. The public way (drive way) for the B-exit discharge was observed flooded with a depth of approximately 6 inches of accumulated water.

In an interview on the same day at approximately 11:00am, the Director of Maintenance stated that the water accumulation resulted from the recent rain the night before and that the drainage in this area is not equipped to handle the water load. He also stated that the water is supposed to be pumped out before it accumulates in the area.

2000 NFPA 101 LSC 7.1.10.1
NYCRR 711.2(a)(1)

Based on observation and staff interview, the facility did not ensure that stairways are enclosed with construction having at least a one hour fire resistance rating. Reference is made to an emergency exit stairwell door that was held open by floor magnet.

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

The findings are:

During life safety inspections on 6/10/10 at approximately 9:30am it was observed that the center stairwell door that opens into the boiler room was held in the open position with a floor magnet. No one was observed in the area at the time of the observation.

In an interview at this time, the Director of Maintenance stated that the door should remain closed and that the magnet would be removed since it is not connected to the building's fire alarm system.

NYCRR 711.2(a)(1)