Indian River Rehabilitation and Nursing Center

Based on observation, medical record review and staff interview the facility did not ensure the resident had the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Specifically, for 4 (# 's 2, 85, 95, and 98) of 4 residents reviewed with restraints the facility did not : recognize that seat belts and a Merri-walker (MW) were restraints for the identified residents, accurately assess the resident's ability to remove the restraints and therefore had no physician's order or Comprehensive Care Plan (CCP) in place with interventions to ensure the least restrictive restraint was utilized. This resulted in no actual harm but has the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following information:

Resident #2
The resident was admitted to the facility on 7/3/2009 with diagnoses of dementia, hypertension and anxiety. The Minimum Data Set (MDS) dated 8/14/11 assessed the resident usually was understood, usually understands and had moderately impaired cognitive decision making ability. The resident used a walker and a chair that prevents rising daily.

The physician's orders dated 10/21/11 did not document an order for the MW.

The CCP for restraints, dated 9/30/09, documented the resident used a geri-chair with a tray as necessary due to restlessness, agitation and when a change was needed from the MW. There is a note on this CCP that stated the resident can release her MW when prompted.

The nurse's notes dated 8/23/11 documented the resident slid out of the MW without injury. On 9/29/11 the nurse's notes documented the resident lowered herself to the floor in the MW.

On 11/3/11 in the afternoon, the resident was asked by the Registered Nurse Manager (RNM) to exit the MW and was unable to do so . The RNM stated the resident exits the MW by lowering herself to the floor and scooching out below the bars.

The MDS 3.0 guidelines for restraint's, and the use of a MW were reviewed with the RNM on 11/3/11 in the afternoon. The RNM added the MW to the care plan as a restraint on 11/3/11.

During an interview on 11/4/11 at 1:30 pm the RNM stated that reading the MDS 3.0 made it perfectly clear that the MW was a restraint. The RNM then produced a Physical Restraint Decision Tree that was dated 11/4/11. The final decision was to care plan the MW as a restraint.

Resident 85:
The resident was admitted to the facility on 7/4/11 with diagnoses of Parkinson's, and anxiety. The MDS dated 10/24/11 assessed the resident had moderately impaired decision making ability with a BIMS score of 8. The MDS of 9/13/11 scored the resident with a 10 and prior to that the MDS dated 9/5/11 scored the resident as 13. This indicated the resident has had a cognitive decline.
The MDS of 9/13/11 assessed the resident used no restraints.

The CCP for Falls dated 7/4/11, documented that the resident is impulsive with poor judgment and inability to judge physical limitations has documented an intervention dated 8/2 /11 of a Velcro release belt to the wheelchair to maintain safety related to spasticity. The CCP also documented the resident was able to release the belt therefore it was not a restraint.

The resident was observed in a wheelchair with a belt restraint in place on 11/4/11 at 9:30 am.

On 11/4/11 at 10:00 am the Registered Nurse MDS coordinator (RNC) asked the resident , with the surveyor present, to release the belt and the resident was not able to.
During an interview on 11/4/11 at 10:50 am The RNM and RNC agreed the resident was cognitively impaired and would not understand the use of the restraint.

Resident 95:
The resident was admitted to the facility on 10/11/11 with diagnoses of dementia, hypertension and depression. The MDS dated 10/18/11 assessed the resident had short and long term memory impairment and moderately impaired decision making ability. The MDS documented the resident did not use a restraint.

The CCP for Accidents and Incidents documented the resident uses a lap reminder belt.

The physicians orders dated 10/11/11 were reviewed and there was no order for a restraint.

The resident was observed on 11/4/11 at 10:00 am with a belt restraint on.

A nurses note dated 10/27/11 documented the resident had noted confusion and was attempting to remove the belt over his head.

On 11/4/11 at 11:35 am the RNC, with the surveyor observing, asked the resident to release his seat belt. The resident could not remove the seat belt.

During an interview on 11/4/11 at 11:40 am the RN float nurse stated she has seen him remove the seatbelt and he may try to do it unsafely. The RNM stated if it's a restraint we have to call it a restraint.

10NYCRR 415.4 (a)(2)(iv) (4)

Based on medical record review, staff interview and observation, the facility did not ensure services provided or arranged by the facility met professional standards of quality for 2 (#s 8, 200) of 24 residents and 3 of 3 units reviewed during the standard recertification survey. Specifically, the facility did not ensure physician's orders for Xanax (medication used for anxiety) and Insulin (medication used to lower blood sugar) were clarified prior to administration(resident's #s 8 and 200). In addition, licensed staff were signing for nourishments they could not verify were administered (3 of 3 units). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident #200
The resident was admitted on 7/11/02 with diagnoses of seizures, dementia and glaucoma. The Minimum Data Set dated 6/5/11 assessed the resident as having severely impaired cognitive skills for daily decision making.

The physician's orders dated 7/7/11 documented the resident was to receive Xanax 0.25mg tablet (tab) give 1/2 tab ( 1.25mg ) by oral route at hours sleep as needed.

The Medication Administration Record dated July 2011, documented the resident was to receive Xanax 0.25mg tablet (tab) give 1/2 tab ( 1.25mg ) by oral route at hours sleep as needed, and the resident received this medication on 7/9/11 and 7/13/11.

The Medication Administration Record dated August 2011, documented the resident was to
receive Xanax 0.25mg tablet (tab) give 1/2 tab ( 1.25mg ) by oral route at hours sleep as needed, and the resident received this medication on 8/6/11, 8/7/11, 8/9/11, 8/11/11, 8/12/11 and 8/14/11.

There was no documentated evidenced the order was clarified with the physician, prior to administration of this medication.

During interview on 11/7/11 at approximately 8:45 am, the Registered Nurse Unit Manager (RNUM) stated that the 11:00 pm-7:00 am and 7:00 am-3:00 pm nurses usually check the physician's orders. When shown the above order for Xanax, and the 2 MARs, the RNUM stated she would expect the order would have been clarified with the physician.

During an interview on 11/8/11 at approximately 10:00 am, the Director of Nursing stated she would also expect the nurses to clarify the above Xanax order.

Resident #8
The resident was admitted on 3/20/2000 with diagnoses of chronic kidney disease, diabetes and cerebral vascular accident. The Minimum Data Set dated 10/9/2011 assessed the resident was able to understand and was understood.
The physicians order dated 10/21/2011 documented an order for Novolog 100 units/milliliter(ml)subcutaneous (SQ), inject by SQ route as per insulin sliding scale protocol;150-199 give 1 unit; 200-249 give 2 units; 250-299 give 3 units; 300-349 give 4 units; and greater than 349 give 5 units. There was no documented numbers of time per day to do a fingerstick blood sugar or administer the insulin.
The November 2011 medication administration record (MAR) documented the same as the above.
During interview on 11/2/11 in the afternoon the Licensed Practical Nurse (LPN) medication nurse, when shown the MAR stated the order does not state how often to perform the fingerstick and administer the insulin. The LPN agreed it was not a complete order.
In addition, the November MAR documented " Document snack and hydration pass at 10:00 am and 8:00 pm".
During an interview on 11/2/11 in the afternoon, the LPN medication nurse was asked if she was responsible for giving the resident the snack and hydration and she stated that the aides give the nourishment. The LPN was then asked if she was present and aware of what the resident actually was offered. The LPN stated no, that she could not know what each resident was offered because she could not be everywhere at the same time. The LPN was asked if she saw 50% being given and she did not respond. The LPN stated she arrived at work on 6/6/11 and this was documented on every MAR. The LPN stated she did not like signing for something she did not see happen.
Finding:
During an interview on 11/4/11 at approximately 11:00 am, a Registered Nurse on C Unit was asked about if the MARs on the unit contained the directive to Document hydration and snacks twice a day. The RN stated yes, it was on every MAR. The RN was asked if she was able to verify that all resident received hydration and snacks at 10:00 am. The RN stated this has been the cause of descension among the staff. She stated she could not know what each resident was given. She stated she wanted to know what the diabetics were receiving.
During an observation on 11/4/11 at 11:35 am a certified nurses aide (CNA) was observed passing nourishments. The CNA was asked if these were the 10:00 am nourishments and she responded yes. She stated they were late because there were only 4 aides on the unit. There were no licensed staff present.
10 NYCRR 415.11(c)(3)(i)

Based on medical record review, and staff interview, the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (#113) of 5 residents reviewed comprehensively during the standard recertification survey. Specifically, the resident developed a red area to her skin after a hot water bottle was placed on her back. This resulted in no actual harm, with the potential for more then minimal harm that is not immediate jeopardy. The findings are:

Resident #117
The resident was admitted to the facility on 10/26/11 with the diagnosis of diabetes, hypertension, and cardiomyopathy. No Minimum Data Set (MDS) was available as it was still in progress.

During an interview with the resident on 11/3/11 at 10:00 am, she stated that the second night she was in the facility she was burned on her backside by a hot water bottle. The resident stated she was hesitant to tell the surveyor as she did not want anyone to get in trouble, because she knew staff shouldn't have done it.

The physican's orders did not document an order for a hot pack or hot water bottle.

The nurses notes from 10/26/11- 11/3/11 did not document anything related to what the resident reported.

A physican's progress note dated 11/3/11 at 2:11 pm documented the resident was seen for a concern of a skin area, likely a burn from warming item used to alleviate back pain. On exam, left of midline there was an area, angular in shape, not open but appearing as a deflated blister, erythematous (red) in color. Length per nursing note, but approximately 2 centimeters (cm) in each direction forming an "L". no drainage, no signs of secondary infection and no other areas observed. Plan was to observe each shift with further intervention if any sign of inflammation, drainage or pain. Source of burn is under investigation.

An incident and accident report (I&A) dated 11/1/11 at 9:30 am, documented that the resident reported that she had complained of back pain and was given a "hot pack". The resident was noted to have a red area 2 1/2 x 1/2 cm on the left lower back. The resident was noted to be alert and oriented.

The Resident Investigation attached to the I&A and dated 11/1/11 documented that on the night shift of 10/31/11- 11/1/11 the resident requested a hot pack for her back from the Registered Nurse (RN). The RN instructed a certified nurses aide (CNA) to fill the hot water bottle and place it on the residents back. The CNA did so, however instead of using tap water the CNA stated she had used water from the coffee dispenser. The RN stated that she did not specify what to fill the hot water bottle with, and did not witness the CNA fill the bottle. The RN stated she checked in on the resident to see if it was working, and that the resident stated it was, but also that it was a little warm. The RN moved the bottle to increase the wrap around the bottle, to which the resident stated "that's much better". The RN also stated that when she moved the bottle she did not notice any discoloration on her skin at the time. Both employees received education that only tap water should be utilized as it allows for temperature control.

Observation on 11/8/11 at 1:40 pm of the hot water dispenser of the coffee machine in the nourishment room behind the "C" wing nurse's station revealed the temperature of the water to be 180 degrees.

During an interview on 11/8/11 at approximately 8:30 am the Registered Nurse/ Unit Manager (RNUM) stated she was new to the UM position, and was actually unaware the facility utilized hot water bottles prior to this incident. When asked her expectations regarding hot bottles, the RNUM stated she would expect the RN to instruct the CNA when to apply a water bottle, and she would also expect the CNA to use tap water to fill the bottle, and then wrap the hot water bottle in a towel prior to applying. The RNUM also stated she would expect the nurse to monitor the resident after the hot water bottle was applied.

During an interview on 11/8/11 at approximately 10:00 am, the Director of Nursing (DON) stated she was unaware there was a policy for hot water bottles, however, she would expect the RN to observe where the water was dispensed from, and feel the hot water bottle prior to application. The DON also stated the facility is no longer utilizing any hot water bottles, and staff are all being re-educated regarding this new policy.

10NYCRR 415.12(h)(1)

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 and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law for 1 (#200) of 2 residents reviewed during the standard recertification survey. Specifically, the facility did not thoroughly investigate an allegation of abuse. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY. This is evidenced by:

Resident #200
The resident was admitted on 7/11/02 with diagnoses of seizures, dementia and glaucoma. The Minimum Data Set dated 6/5/11 assessed the resident as having severely impaired cognitive skills for daily decision making.

A progress notes dated 7/1/11 at 11:16 pm by a Registered Nurse (RN) documented the RN was requested by the Certified Nurse's Aide (CNA) staff to speak with the resident. The note documented the resident stated the RN was "rough with her" and the resident became physically and verbally abusive to the CNA staff, stating "you know what you did you asshole". The note further documented the RN tried to explain to the resident that he had not seen the resident and had not been in her room that evening, however, the resident continued to be verbally abusive to staff members. The RN documented he stood outside the resident's door, and the resident made no other accusations regarding other staff members.

The "Resident Grievance or Concern" form initiated 7/1/11 and completed 7/4/11 documented the "resident called a CNA an asshole'. She didn't give any further details as to what her complaint actually was." There was no documentation the resident stated the RN was "rough with her". Under the section entitled "Follow-up Information: staff contacted/interviewed", this form documented "please refer to written report".

Attached to this report, was a copy of the progress notes dated 7/1/11 at 11:16 pm, a statement from the RN, and a document entitled "Resident Investigation", which was signed and dated by the Director of Nursing (DON) on 7/4/11.

The DON documented "I brought the concern to the Interdisciplinary Team (IDT) and after careful review have determined that we do not find evidence of abuse, neglect or mistreatment." There was no evidence the CNA's who were present had been interviewed regarding the resident's statements.

During interview on 11/7/11 at approximately 11:35 am, the RN who documented the 7/1/11 progress note, stated he notified the DON after the incident occurred, and the DON instructed him to write a statement. The RN also stated he spoke to the CNA's involved, but doesn't remember if he documented his conversation with the CNA's. The RN stated in hindsight, he should have documented the CNA's statements, however, he "knows" no one was rough with the resident.

During interview on 11/8/11 at approximately 10:00 am, the DON stated she knows that she and the RN interviewed the CNA's and should have documented their statements, however she was unsure why there were no statements attached with the report. The DON was unable to produce the statements from the CNA's.

10 NYCRR 415.4(b)(1)(ii)

Based on medical record review and staff interview the facility did not ensure that a resident
maintained acceptable parameters of nutritional status for 1 (#46) of 4 residents reviewed for weight loss during the standard recertification survey. Specifically, the facility did not assess and intervene timely a residents significant weight loss. The resident had an initial weight loss of 14.1 pounds (lbs) (9%) and the residents weight continued to trend down for a total weight loss of 23.6 lbs (approximately 15%). This resulted in no actual harm but has the potential for more than minimal harm. The findings are:

Resident #46
The resident was readmitted on 5/24/11 with diagnoses of Alzheimer's, high blood pressure and osteoarthritis. The Minimum Data Set (MDS) dated 9/5/11 assessed the resident as being severly impaired for decision making.

The residents weekly weight record revealed the following weights: September 3, 2011- 155.6 pounds, September 11- 141.5 pounds, September 24- 138.5 pounds, and October 1- 132 pounds.

The facilities policy and procedure titled "Weight Assessment and Intervention" revised on 12/2008 identified that residents were to be weighed, weekly, unless otherwise specified. Under Policy Interpretation and Implementation it was documented any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. The criteria for determining significant weight loss was 5% in one month, with severe loss being more then 5%, 7.5% in 3 months with greater then 7.5% being a severe loss and 10% in 6 months with greater then 10% being a severe loss. The dietician, with input from nursing and medical staff will note individual weight goals for each resident in the nutrition care plan. Under Analysis it was documented at patient care conferences information about weight trends shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the resident's target weight range, approximate calorie, protein, and other nutrient needs compared with the resident's current intake; the relationship between current medical condition or clinical situation and recent fluctuations in weight; and whether and to what extent weight stabilization or improvement can be anticipated.

The "Care Plan Activity Report" form initiated 6/22/10 and revised 8/24/11 documented under "Activity of Daily Living-Eating" that the resident is independent with intermittent supervision (set up tray, cut foods). Interventions initiated 6/22/10 with no revision date documented supervise meals in dining rooms, and encourage to complete meals.

The "Care Plan Activity Report" form initiated 6/17/10 with no revision date documented under "Nutrition" goals maintain weight 150+/- 5%. Interventions initiated 6/17/10 with no revision date documented regular diet, monitor weight weekly and offer snacks in the am/pm.

The "bowel movement list" form was reviewed for the month of September 2011. There was no documented evidence that the resident had an increase in bowel movements.

The Certified Nurses Aide (CNA) care card documented under eating - supervision, setup only dining room, nourishment type was a regular diet as tolerated.

The Registered Dietician (RD) progress note dated 9/29/11 documented that the residents intake is 25-100%, with an average of 52%, and receives Prostat (a protein supplement) and a Multi Vitamin. The residents weight is 138.5 pounds this week which is unlikely as it would be a large drop, and will need to recheck.
There is no documented evidence in the residents medical record that a re-weight was done.

The RD documented on 10/26/11 that the residents weight was down 16.1 pounds and has been lower. The RD documented she does not know why she dropped down last month. The note documented if resident looses more weight to add shakes.

During an interview on 11/7/11 at 9:00 am the registered nurse manager (RNM) stated if a resident had an increase or decrease of 3 pounds or more she would notify dietary. The RNM stated she reviews the weekly weights, every week and if concerns are found then the residents are discussed at the weekly weight meetings. The RNM stated she could not recall if she notified dietary of this residents weight change in September.

During an interview on 11/7/11 at 9:20 am the licensed practical nurse (LPN) stated the CNA does the weekly weights and then she documents them in the residents record. The LPN stated if a resident has an increase or decrease of 3 pounds or more she would notify RNM.

During an interview on 11/7/11 at 10:00 am the CNA stated the resident eats in the dinning room and is supervised. The CNA stated residents best meal is breakfast and the resident does not eat well at lunch, as she moves things off and around her tray.

During an interview on 11/7/11 at 10:30 am the surveyor asked the physician if she was notified of the residents weight loss in the month of September, the physician stated the resident moved to another unit on 7/28/11. The resident had a broken arm and was casted (removed at the end of August) and was diagnosed on 8/26/11 with Clostridium Difficile and was being treated with Vancomycin. The physician stated she thought the weight loss was brought to her attention but believed these events could have contributed for the residents weight loss in September. She additionally stated she would expect to be notified with a
significant/continued weight loss. There is no documented evidence in the residents medical record that the physician was notified of this residents 23.6 pound weight loss.

During an interview on 11/8/11 at 8:40 am the RD stated she comes to the facility twice a week and does not participate in the weekly weight meeting, the Dietary Manager (DM)does. The DM would notify her by e-mail, phone or would leave a note for the RD if there are concerns about weight changes. The RD stated she was aware that the resident had lost weight and was aware she moved from one unit to another and she did recommend dietary changes with her last note on October 26, 2011.

During an interview on 11/8/11 at 9:30 am the DM stated she does not participate in the weekly weight meetings and that she monitors the weights by looking at the reports in the computer. The surveyor asked the dietary manager if she could view weights/re-weights that are documented in the nurses progress notes the dietary manager stated no as she does not know how to access them.

The nurses progress notes dated 9/1-9/18/11 revealed the resident was being treated for Clostridium Difficile and the resident had no complaints of nausea or vomiting and had no watery stools.

10NYCRR 415.12(i)(1)

Based on observation and staff interview, it was determined that the facility did not protect all cooking facilities in accordance with the Life Safety Code and the 1998 edition of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operationsnone (NFPA 96) and the 1998 edition of NFPA 10, Standard for Portable Fire Extinguishersnone (NFPA 10). Subsections 7-1.2 and 7-2.1 of NFPA 96 require that cooking equipment that produces grease-laden vapors such as ranges shall be protected by fire-extinguishing equipment. Subsection 3-7.1 of NFPA 10 requires placement of K-rated extinguishers where there is a potential for fire from vegetable or animal oils and fats.

These requirements are not met. Specifically, an electric griddle located on C unit (one of three units), lacked automatic fire suppression and the proper fire extinguisher was not provided. This results in the potential for more than minimal harm that is not immediate jeopardy and is evidenced as follows:

The food holding room within the C unit dining room contained an electric griddle. This griddle lacked automatic fire suppression when observed on 11/8/11 at 12:30 pm. Additionally, a K rated fire extinguisher was lacking in this location. The Food Service Director was interviewed on 11/8/11 at 11:20 am regarding use of the cooktop on C unit, who stated that it is used every day for purposes of cooking fried eggs and french toast. This cooktop unit has been in use for approximately six weeks.

10 NYCRR 415.29, 711.2(a)(1)(3)(25), 2000 NFPA 101; 19.3.2.6, 1998 NFPA 10, 1998 NFPA 96

The following requirement of the Life Safety Code was previously waived. The results of the current survey and review of the facility's previously submitted justification reaffirm correction would pose an undue hardship and, that adequate safeguards remain in place to safeguard residents, staff and visitors. The continued waiver of the following item is recommended.

Corridors required for emergency egress exit shall be at least 8 feet in clear unobstructed width.

The service corridor for the 1970 building was built with a 6-foot clear width. The 1991 addition was attached to this service corridor. This under sized corridor is used by residents to travel to and from the existing building and to reach the main front entrance and other service/office areas.

The waiver requested is based on the fact that the existing condition constitutes a sufficient hardship due to spatial and physical limitations as follows: the only practical expansion of the building was through the 6 feet corridor; cost of moving services along the 6 feet corridor (boiler, laundry, dryer room, toilets, and janitor closet) is prohibitive.

2000 NFPA 101 4.6.7, 18.2.3.3; 10 NYCRR 415.29 (a)(2), 711.2 (a)(1); 1997 NFPA 101 1.3.7, 12-2.3.3