Table of Contents
Tarrytown Hall Care Center
Deficiency Details, Certification Survey, March 28, 2011
PFI: 1115
Regional Office: MARO--New Rochelle Area Office
F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: May 25, 2011
The facility must 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.
Citation date: March 28, 2011
Based on interviews, record reviews and observations, the facility did not ensure that the resident environment remained free of accident hazards as is possible.
Specifically, on 3/21/11 at 9:30AM, the water temperature in a resident/visitor accessible bathroom on Unit 1 was observed to have very hot water.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
During the initial tour of the facility on 3/21/11 at 9:30AM the water temperature in a resident accessible bathroom was observed to be hot to the touch. An immediate check of the water temperatures in rooms 100, 103, 110,117 and the men's toilet facilities on Unit 1 revealed water temperatures between 122 and 128 degrees. Acceptable water temperature parameters are within 90-120 degrees.
At 10:30AM on this day a review of the facility Daily Hot Water Temperature Log, for the month of March revealed that on 3/9/11 at 9:00AM, the water temperature in room 109 was 124 degrees. Subsequent to 3/9/11 through 3/21/11 at 8:45AM, the Daily Hot Water Temperature Logs documented temperatures throughout the facility to be within the acceptable parameters of 90-120 degrees.
In an interview with the Director of Maintenance on 3/21/11 at 11:10AM, he stated that the maintenance worker did not report this 3/9/11 temperature of 124 degrees in room 109 to him. When asked if he had seen the log he stated that he had. He had no explanation as to why he did not act on this knowledge.
In an interview of the maintenance worker on 3/28/11 at 9:00AM, he stated that he had reported that the temperature in room 109 was 124 degrees and he had left the log for the Director to review.
In an interview with the Administrator on 3/21/11 at 11:45AM, he stated that he was not informed of the elevated water temperature and would investigate immediately and take whatever precautions necessary to remedy this situation, including lowering the mixing valve settings and/or calling a plumber to check the mixing valve.
At this time a review of the Incident and Accident logs by surveyors revealed that there were none involving hot water.
On 3/22/11 at 8:45AM, the Hot Water Temperature Log noted temperatures between 124 and 130 degrees in some rooms on all three units. At 9:15AM the Director of Maintenance stated that the plumber would be called immediately. In an interview with the Administrator at 9:30AM on this day, he reiterated that the plumber would be called immediately, all showers would be stopped, residents would be given bed baths and monitored closely, all staff would be informed of the situation and water temperatures would be monitored every 2 hours to ensure resident safety.
Interview of the Licensed Practical Nurse on Unit 2 on 3/22/11 at 1:00PM revealed that staff had not reported any issues with hot water being a problem. She stated that staff always ran the shower water to acceptable temperatures, testing these for residents prior to placing the resident under the water. In an interview with the Certified Nursing Assistant (CNA) immediately after this, the CNA stated that she always mixes hot and cold water "to just a little warm" prior to placing a resident in the shower to ensure that residents are safe.
Interviews of the Unit Manager Registered Nurses on Units 1 and 3 revealed that there were no concerns regarding water temperatures on either unit.
On 3/23/11 at 10:00AM, in response to surveyor follow up of the water temperature situation, the Director of Maintenance told the surveyor that the plumber never showed up or returned facility's call on 3/22/11. In an interview with the Administrator on this day at 10:30AM, he stated that another plumber was called and would be in before 1:00PM. Review of the Daily Hot Water Temperature Log for the previous 24 hours revealed that temperatures were within acceptable ranges, i.e., between 90 and 120 degrees.
In an interview with the Plumber on 3/23/11 at 3:30PM he revealed that the temperatures were being monitored every 2 hours and that he was locating a mixing valve for the boiler.
On 3/24/11 and 3/25/11 facility documentation revealed that water temperatures continued to be taken every 2 hours to ensure that the mixing valve was functioning properly and temperatures were within acceptable parameters.
415.12(h)(1)
F159 483.10(c)(2)-(5): FACILITY MANAGEMENT OF RESIDENT FUNDS
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: May 25, 2011
Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c)(3)-(8) of this section. The facility must deposit any resident's personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund. The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. The facility must notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.
Citation date: March 28, 2011
Based on interview and record review, the facility did not ensure that resident personal funds greater than $50.00 were maintained in an interest bearing account.
This resulted in potential for more than minimal harm.
Findings are:
Review of a list of resident funds dated 3/28/11 revealed 84 of 114 residents currently residing in the facility, had a personal funds account with the facility. Of the 84 residents with a personal funds account, 67 had accounts with over $50.00. Additionally, of the 67 residents whose accounts exceeded $50.00, 20 had accounts that were over $1000.00, with one resident having an account with over $10,000.00.
In an interview the personal funds account manager on 3/28/11 at 11:15AM she stated that the money for the residents is held in a non-interest bearing checking account. Consequently interest is not accrued on the money that the facility holds for the residents.
415.26(h)(5)(i)
F156 483.10(b)(5) - (10), 483.10(b)(1): INFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.
Scope: Pattern
Severity: Potential for no more than Minimal Harm
Corrected Date: May 25, 2011
The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under ¾1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing. The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section. The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. The facility must furnish a written description of legal rights which includes: A description of the manner of protecting personal funds, under paragraph (c) of this section; A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels. A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.
Citation date: March 28, 2011
Based on record review and interview, the facility did not advise residents of their right to appeal termination of Medicare benefits. This occurred for 2 of 3 residents reviewed, both of whom no longer reside in the facility (Residents # 15 and # 8).
This resulted in no actual harm with no more than minimal harm that is not immediate jeopardy.
1. A review of the "Notice of Medicare Provider Non-Coverage" form revealed that Medicare coverage for Resident #15 ended on 11/29/10. There is no evidence that the resident or resident representative was advised of the right to appeal the termination of Medicare benefits.
During interview with facilty administrator on 3/28/11 at approximately 10:30 AM, he was unable to offer an explanation as to why the appropriate notification was not made.
2. A review of the "Notice of Medicare Provider Non-Coverage" form revealed that Medicare coverage for Resident # 8 ended on 2/25/11. There is no evidence that the resident or resident representative was advised of the right to appeal the termination of Medicare benefits.
During interview with facilty administrator on 3/28/11 at approximately 10:30 AM, he was unable to offer an explanation as to why the appropriate notification was not made.
415.3(g)(2)(i)(iv)
K18 NFPA 101: CORRIDOR DOORS
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: May 25, 2011
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities.
Citation date: March 28, 2011
Based on observation and interview it was determined that the facility did not ensure that there is no impediment to the closing of doors protecting corridor openings in case of emergency in that all of the corridor doors to private resident rooms are impeded from closing when the bathroom doors in these rooms are fully opened. This was evidenced on three of three n ursing u nits observed.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
On 3/24/11, during life safety rounds beginning at 10:20AM , it was observed that , when fully opened, bathroom doors in all of the private resident rooms would impede the corridor doors from being closed.
The private rooms identified include:
Room # 105, 111, 113, 213, 211, 207, 205, 305, 310, 311, 312, 313, 314, 316, 318, and 320.
In an interview on 3/21/11 at 10:30AM the Director of Maintenance stated that the doors were designed as observed.
NFPA 101 (2000 edition) 19.3.6.3, 7.1.10.1
10NYCRR 711.2(a)(1)
K38 NFPA 101: EXIT ACCESS
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: May 25, 2011
Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1
Citation date: March 28, 2011
Based on observation and interview the facility did not ensure that exit access is so arranged that all exits are readily accessible at all times in accordance with 7.1 in that:
1. The path of egress leading out of two locations in the facility was blocked by a dumpster.
2. Four of four delayed egress doors inspected did not release when pressure was applied for 15 seconds.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy:
Findings are:
1. On 3/21/11 at 9:30AM during life safety rounds it was observed that a dumpster was blocking the path of egress from both the main Dining Room and the PT/OT Department exits .
In an interview on 3/21/11 at 9:40AM the Director of Maintenance stated that the dumpster would be moved.
2. On 3/21/11 at 10:10AM during life safety rounds four of four 15-second delayed egress fire exit doors, located by Room 116, the Activities Department, 1st floor South, and by Room 219 failed to open when pressure was applied to the doors for the required 15 seconds. When the release code was entered, the doors opened.
In an interview on 3/21/11 at 10:30AM the Director of Maintenance stated that he would adjust and monitor the doors.
NFPA 101 (2000 edition) 19.2.1, 7.1.10, 7.2.1.6
10NYCRR 711.2(a) (1)
K25 NFPA 101: SMOKE PARTITION CONSTRUCTION
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: May 25, 2011
Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4
Citation date: March 28, 2011
Based on observation and interview the facility did not ensure that smoke barriers are constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3 in that six of six barrier doors located on three of three nursing units had 1/4 inch gaps running the entire length of each door, between the frame and inside edge of the door.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings are:
On 3/24/11 at 10:20AM during a test of the fire alarm system it was observed that the
double set of barrier doors located on three of three Nursing Units had a 1/4 inch gap running the entire length of each door. The gaps were located between the door and frame .
In an interview on 3/24/11 at 10:40AM the Director of Maintenance stated that the gaps would be corrected.
NFPA 101 (2000 edition) 19.3.7.5
10NYCRR 711.2(a) (1)
K50 NFPA 101: FIRE DRILLS
Scope: Pattern
Severity: Potential for no more than Minimal Harm
Corrected Date: May 25, 2011
Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2
Citation date: March 28, 2011
Based on record review and interview the facility did not ensure that fire drills are held under varying conditions in that no scenario was described in the documentation for twelve (12) of twelve (12) drills reviewed .
This resulted in no actual harm with potential for minimal harm.
Findings are:
On 3/21/10 at 12:10PM during record review it was determined that detailed scenarios were not documented for 12 of 12 fire drills reviewed in that the drills were classified or described as simply "fire", or "s moke " with no further elaboration. The critiques given for the drills were minimal and repetitive.
In an interview on 3/21/11 at 1:30PM the Administrator and Director of Maintenance acknowledged the observation(s).
NFPA 101 (2000 edition) 19.7.1.2
10NYCRR 711.2(a)(1)