Blossom View Nursing Home

Based on observations, staff interviews, and record reviews, it was determined after review of the infection control program that the facility did not provide a safe, sanitary environment to prevent the potential transmission of infection. The issues involved the lack of an infection control program that demonstrates ongoing surveillance, recognition, investigation, and control of nosocomial (facility acquired) infections to prevent the onset and spread of infection, to the extent possible. Additionally, a blood glucose machine was not cleaned after use and personal protective equipment was not used in a precautions room. This resulted in no actual harm with potential for minimal harm that is not immediate jeopardy that is widespread, and is evidenced by the following:

1. Review of the infection control program with the Registered Nurse/Infection Control Representative (ICR) on 4/28/11 at 2:50 p.m., revealed that surveillance data did not include records of nosocomial acquired infections. The ICR reported that the facility does not track the source of infections or calculate infection rates. When asked if she collects, analyzes, and uses data related to infections to identify and prevent the spread of infections and to adjust its infection prevention control program, the ICR stated that this is done but not documented when she looks at the charts every two weeks. The ICR said she should change her process.

2. During an observation of medication administration on 4/28/11 at 4:38 p.m., the evening Licensed Practical Nurse (LPN) obtained a blood glucose level for Resident #92. Upon completion, the LPN removed the used glucose strip from the glucometer machine and without cleaning it, she placed the machine in the top drawer of the medication cart in a box containing clean blood glucose supplies. When interviewed at 5:00 p.m. that day, the LPN reported that she had finished the medication pass. She stated that she knew she should clean the blood glucose machine before she put it in the drawer but forgot to do so. The LPN said she should have cleaned the blood glucose machine with germicidal disposable cloths after checking the resident's blood glucose.

Review of the facility's undated policy regarding blood glucose monitoring revealed that blood glucose machines are to be cleaned with disinfectant wipes and air dried before the next use.

3. Resident #20 has diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA) in the urine. The 3/4/11 Comprehensive Care Plan and the 3/5/11 Minimum Data Set Assessment for daily decision making both revealed that the resident is always incontinent. Physician orders, dated 4/21/11, read, "positive MRSA" and urinary tract infection. Orders dated 4/25/11, included Contact Precautions due to MRSA in urine.

The following observations and interviews were made on 4/26/11:

a) At 10:01 a.m., an orange sign posted outside the room read, "Stop Precautions in use, please see nurse before entering."

b) At 10:05 a.m., LPN #1 reported that the resident is on contact precautions and told the surveyor to wear a gown and gloves into the room because the resident has MRSA in her urine.

c) At 11:05 a.m. upon entrance to the room, the surveyor found no gowns in the plastic storage bin. Also at this time, the housekeeper was making the bed and was not wearing a gown. When asked if she should be wearing a gown, the housekeeper said she was told she only needed to wear gloves.

d) At 11:06 a.m., LPN #2 said she did not know if a gown should be worn in the resident's room. LPN #2 then asked the LPN Case Manager, who said gowns and gloves need to be worn when entering the room.

e) At 11:23 a.m., the resident's daughter said that she was never told she needed to wear anything when entering the room.

When interviewed on 4/29/11 at 4:10 p.m., the Registered Nurse Manager reported that the resident is on contact precautions, which requires wearing a gown and gloves when entering the room.

The facility's policy regarding MRSA, dated October 2010, includes that a gown is to be worn when entering the room if clothing will have substantial contact with the patient environmental surfaces or items in the patient's room, or if the patient is incontinent.

[10 NYCRR 415.19(a)(1-3)(1)(2)]

Based on resident and staff interviews, and record reviews, it was determined that for two of six residents reviewed for quality of care, the facility did not provide the necessary interventions to meet the residents' highest level of physical functioning. The issue involved lack of timely bowel management for Residents #202 and #108. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #202 was admitted on 4/21/11 with a history of constipation. The Hospital Admit/Discharge Summary for Nursing Home residents, dated 4/20/11, revealed that the resident is given stool softeners to treat constipation and last had a bowel movement (BM) on 4/21/11 after Milk of Magnesia (MOM), a suppository, and a Fleet's enema were given. The facility's Nurse Admission Form, dated 4/21/11, documented that the resident was prone to constipation. Physician (MD) orders, dated 4/21/11, included to give MOM daily as needed for constipation and Norco (causes constipation) for pain management. No MOM was given from 4/21/11 to 4/28/11. The hand documented Care and Treatment Record for BM in use revealed that the resident did not have a BM from the evening of 4/21/11 until the day shift on 4/26/11. The 4/26/11 Minimum Data Set (MDS) Assessment revealed that the resident had no cognitive impairment.

When interviewed on 4/25/11 at 4:03 p.m. and 5:00 p.m., the resident stated, "I haven't had a BM since I've been here. I've told the nurse aides and the nurses but I haven't gotten anything for it yet. It is so horrible!"

During interviews on 4/25/11 from 4:25 p.m. to 4:46 p.m., the Certified Nursing Assistant (CNA) #1, CNA #2, and CNA #3, all stated that they record resident bowel movements on the BM log in the green binder and that the nurses check the logs every night. In other interviews that day between 4:51 p.m. to 4:55 p.m., Licensed Practical Nurse (LPN) #2 and the LPN Case Manager both stated that bowel records should be checked every shift to ensure that residents receive bowel medications according to the facility's policy. They reported that the facility's policy is to start the BM protocol usually with MOM after the resident has not had a BM for two days. After reviewing the MAR and BM log, the LPN Case Manager stated, "She should have been offered the MOM this morning since she has not had a BM since she was admitted." The LPN Case Manager also said that a physician would be called if the BM protocol was not successful.

In a follow-up interview on 4/26/11 at 9:49 a.m., the LPN Case Manager stated that after reviewing the facility policy for bowel management, she found that if the resident does not have a BM by the third day, then medication is given.

In an interview on 4/27/11 at 3:13 p.m., the resident stated she did have a large BM that morning but had not received any bowel medications since admission.

Interviews conducted on 4/28/11 are as follows:

a) At 12:12 p.m., the LPN Case Manager reported that after surveyor intervention, the evening nurse was asked to give the resident MOM after dinner on 4/25/11. The LPN Case Manager could not find that the MOM was documented as given at that time. Also, the nurse giving this medication should have documented that it was given.

b) At 4:46 p.m., LPN #4 stated that she looks at the green care books, not the computer, when she reviews a resident's BM history.

2. Resident #108 has diagnoses including Alzheimer's dementia. The Comprehensive Care Plan, dated 11/16/10, revealed the resident is at risk for constipation due to use of narcotic pain medications/diuretics. Approaches include to monitor the resident's bowel elimination and medicate for constipation per the MD orders. The April 2011 MD orders include MOM and/or Dulcolax suppository for constipation.

Review of the BM log book (green log book) revealed that from the 4/12 evening shift through the 4/18/11 day shift, the resident did not have a BM recorded. The April MAR lacked documented evidence that MOM or Dulcolax were signed off as given. A nursing note, dated 4/16/11, includes the resident was given MOM at 6:40 p.m. for constipation with results pending. There are no other notes regarding the resident's bowel status from the 4/12 evening shift through the 4/18/11 day shift.

Interviews on 4/28/11 are as follows:

a) At 11:00 a.m., two CNAs identified the green log book as the location that BMs are recorded.

b) At 1:39 p.m., a LPN said the nurse on each shift is responsible for reviewing the BM log book.

c) At 2:02 p.m., the Registered Nurse Manager said BMs are recorded in the log book, and any of the case managers look at BM sheets on each shift. Also, the nurse should administer MOM no more than three days at the most, chart the results, and assess the resident's abdomen. The nurse should have signed off for the MOM on the MAR.
ne d) At 4:00 p.m., the evening LPN said she checks the green log book, a handwritten log book, for BM history.

The facility's policy entitled, "Laxative Bowel Regime," dated October 2010, directed the following: Chronically constipated residents will be looked at on the individual basis. If there is a physician's order for tablets, ex. Bisacodyl, MOM, they will be administered on the second evening. This will be repeated on the third evening if there are no results. If there is a physician's order for Dulcolax suppository, this will be administered on the fourth morning unless otherwise indicated. If there are no results from the above, the resident will be checked digitally by the nurse, the abdomen ausculated, and palpated and check for bowel sounds. The physician will be notified if further orders are necessary.

[10 NYCRR 415.12]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not maintain exit stairway enclosures. The issue was related to openings through the enclosure wall of an exit stairway. This affected one of one exit stairway, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Observation above the suspended ceiling on 4/27/11 at 10:25 a.m. revealed the exit stairwell that connects the basement to the first floor was not protected by a one-hour fire resistant enclosure. When viewed from the corridor outside the stairwell, two approximately 2-inch diameter metal conduits passed through approximately 4 x 4-inch openings through the concrete block wall. An additional opening through the block wall was observed where two corrugated electrical conduits passed through above the door. The areas between the conduits and the block wall were not filled with a material capable of resisting fire for at least one hour. When these areas were viewed from inside the stairwell, the openings were confirmed to pass through the walls. The exit stairwell serves as a primary means of egress for the basement level.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.3.1.1, 8.2.5.2]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not properly maintain exits. The issue was related to exits from a basement which discharge into a fully enclosed courtyard. This affected one of one basement, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observation on 4/20/11 at 9:40 a.m. revealed the North and South stairway exits serving the basement of the old section (1971 building) of the facility are non-compliant. The addition of the Empire wing to the facility resulted in the stairway exits discharging into a fully enclosed courtyard. To reach a safe public way from the basement via the courtyard, one must re-enter the building to find an acceptable exit leading to a public way.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.2.1, 7.1.10.1, 7.2.2.1, 7.5, 7.7.1]