Victoria Home

Based on observation, record reviews and staff interviews, the facility did not ensure that the care plans were reviewed and revised in a timely manner (1.) to protect a resident (#12) from potential abuse by another resident (#2) with verbally aggressive behavior; (2.) to include additional measures to stimulate a resident's appetite prior to administration of a medication which is used primarily as a psychoactive medication (#3); and (3.) to devise a communication care plan while a resident's hearing aide was not available (#5). This was evident for 1 out of sample resident and 3 sampled residents in a total sample of 11 residents. (Residents #12, #2, #3 and #5)

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

The findings are:

1. Resident #12 is an 85-year old female who was admitted with diagnoses including hypertension, and profound impairment. According to the Minimum Data Set assessment (a type of resident assessment tool) dated 4/16/12, the resident is alert, oriented and has a verbal behavioral symptoms directed towards others.

Resident #2 is a 91-year old male who was admitted with diagnoses including Alzheimer's disease and depression.

A review of the Nurse's Notes of 5/12/12 through 6/4/12 revealed that the resident had exhibited behaviors of verbal aggression and refusal of care on several occasions. On 5/21/12, Resident #2 had a verbal altercation with Resident #12 during mealtime. The facility made adjustments with the seating arrangement to ensure that the two residents don't get in contact with one another.

A review of the Resident-to-Resident Altercation Report dated 6/01/12 revealed that the above residents had another altercation. At approximately 8:40 PM, Resident #2 saw Resident #12 and repeatedly told her " You're a witch! Get out of here, you are so ugly " . Resident #2 then followed Resident #12 as she walked back to her room and calling her a " witch " . A review of the Nurse's Notes of 6/02/12, at approximately 1:00 PM, Resident #2 saw Resident #12 and started calling her a " witch " in the presence of a facility staff member. He then followed her in the hallway as she walked to the lounge area.

Further review of the Nurse's Notes of 6/04/12 revealed that at about 8:30 PM, as Resident #2 was coming out of his room he saw Resident #12 and started to call her names again. The staff intervened by separating the residents, however no further measures were put into place to stop Resident #2's ongoing negative behavior towards Resident #12.

During an interview with the Social Worker on 6/5/12 at 11:50 AM as to why the care plan was not reviewed and revised to address Resident #2's ongoing behavior, she had no response.

2. Resident #3 is an 83-year old female who was admitted with diagnoses including dementia, depression, and osteoporosis.
A review of the Nurse's Notes of 4/18/12 through 5/07/12 revealed that the resident's appetite varied from poor to fair. During an interview with the unit Registered Nurse manager on 6/5/12 at 12:10 PM, she stated that the resident used to be on Remeron but it was discontinued. She stated that it was restarted when the resident begin to show poor appetite. On 5/07/12, the Psychiatrist examined the resident who documented on his consultation report that the resident was " not clinically depressed " but recommended that the resident be started on Remeron 7.5 milligrams to stimulate her appetite. (Remeron is used primarily as a medication to treat depression). The attending physician was then notified on this date and ordered to restart the Remeron.

During an interview with the Diet Technician on 6/05/12 at 12:25 PM, she stated that the resident " really did not have any poor appetite " but that the resident's food and fluid intake was very variable. She stated that the care plan does not need to be revised as her assessment of 3/30/12 did not reveal any changes despite nursing's observations that the resident had poor appetite on many occasions. When asked if nursing made her aware of the resident's poor appetite, she had no response.

Following surveyor intervention, the Diet Technician updated the care plan on 6/05/12 and documented that Remeron was restarted secondary to slight decline in the resident's appetite and decreased alertness during meals. Interventions include monitoring the resident's oral intake, appetite, and alertness during meals. The Diet Technician added that the resident was placed on one-on-one to better monitor her food intake.

3. Resident #5 is a 76-year old male who was admitted with diagnoses including hypertension and cerebro-vascular accident or stroke.

During initial tour of the 3rd Floor unit on 6/5/12 at 8:35 AM, the resident was observed in his room having breakfast. When the surveyor approached the resident to greet him, the assigned nursing aide who was present at that time said that the resident could not hear very well.

A review of the resident's communication care plan dated 4/17/12 revealed that the resident has a hearing aid on the left ear and that the staff must encourage the resident to wear it daily.

During a musical activity on 6/5/12 at 2:00 PM, it was noted that the resident was not wearing any hearing aid and was seated on the far end of the room.

During an interview with the unit Registered Nurse manager on 6/5/12 at 2:30 PM as to why the resident had no hearing aid on the left ear, she stated that it was sent for repair two weeks earlier. The Social Worker added during this interview that it was she who took the hearing aid to the company for repair. When asked as to what measures were put into place while the hearing aid was being fixed, they had no response.

A review of the resident's clinical record revealed no documentation that the hearing aid was not available. The communication care plan was not reviewed and revised to include interventions to ensure that the resident's ability to communicate was not diminished.

Following surveyor intervention, the facility called the company on 6/5/12 to obtain the hearing aid.

415.11 (c)(3)(ii)

Based on record review and interviews, the facility did not ensure that each nurse met professional standards of practice with regards to medication administration. Specifically, the facility did not ensure that a resident received a medication via the route prescribed by the physician and/or initiate a change in the route ordered by the physician to accommodate the resident's "nothing by mouth" (NPO) status, Resident #1.

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

Findings are:

Resident #1 is 102 years old and was re-admitted to the facility on 5/5/11 with diagnoses including Congestive Heart Failure, Cerebral Vascular Accident (Stroke), Atrial Fibrillation, Dementia and Dysphagia (difficulty swallowing) with Status/Post insertion of a Gastric Tube (to feed a person directly into the stomach).

Review of the resident's current physician's orders on 6/6/12 revealed that the resident is NPO and receives nutrition (Periactive 1000 millimeters (mls.) with an auto flush of water 25 mls./an hour to be administered at a rate of 63mls/hour plus an order to flush with 200mls. of water before and after each feeding). Further review of the current phyician's orders revealed an order for Digoxin to be administered by mouth, potentially unsafe for this resident who has Dysphagia. Review of the Medication Administration Record for Resident #1 on this same date revealed that the medication Digoxin was charted as having been administered by mouth.

In an interview with the Licensed Practical Nurse (LPN) who administered medications on 6/ 6/12 at 11:30AM she revealed that she had administered the medication via Gastric Tube. She explained that the resident is NPO. When asked why she had signed that the medication was given by mouth, she was unable to explain.

In an interview with the Unit Manager Registered Nurse immediately subsequent to this, she stated that she should have had the order changed to accommodate the resident's NPO status.

415.11(b)(ii)

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CFR 483.70(a)

K012, S/S=B

The "old building" wing is a wood frame construction, fully protected by an automatic extinguishing system (sprinklers), but is more than one story; the wing has three stories. The first floor has the following resident use areas: living rooms, library, and dining room (no resident sleeping rooms). The facility's main kitchen is also on the first floor. The second floor has offices; the third floor has apartments for staff.

200 NFPA 101: 19.1.6.2
10NYCRR 711.2(a)(1)