Table of Contents
Sky View Rehabilitation and Health Care Center, LLC
Deficiency Details, Certification Survey, August 5, 2011
PFI: 1120
Regional Office: MARO--New Rochelle Area Office
F334 483.25(n): INFLUENZA AND PNEUMOCOCCAL IMMUNIZATION
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: October 4, 2011
The facility must develop policies and procedures that ensure that -- (i) Before offering the influenza immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. The facility must develop policies and procedures that ensure that -- (i) Before offering the pneumococcal immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicated, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. (v) As an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's legal representative refuses the second immunization.
Citation date: August 5, 2011
Based on record review and interview, the facility did not ensure that residents were provided education regarding the risks and potential side effects of influenza and pneumococcal vaccinations. Specifically, residents who refused to be vaccinated were not educated on the risks and benefits of receiving vaccinations. This was evident for 3 of 29 residents reviewed.(Residents #4, #6 and #19).
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
1. Review of the medical record for Resident #4 revealed he refused the influenza vaccine in October 2010. Review of the nurses' notes revealed the attending physician was made aware at that time. Further review revealed no documentation that the resident was educated regarding the benefits and potential side effects of the vaccine.
2. Review of the medical record for Resident #6 revealed she refused the pneumococcal vaccine on 7/8/11 (admission date). Review of the nurses' notes revealed no documentation that she was educated about the potential risks and benefits of the vaccine.
3. Review of the medical record for Resident #19 revealed the resident was offered the pneumococcal vaccine upon admission, 12/20/10. Review of the nurses' notes revealed no documentation that the resident was educated regarding the risks and benefits of the vaccine.
Review of the policy and procedure regarding Influenza and Pneumococcal Immunization (revised on 6/10) documented that education will be provided to the patient/resident or designated respresentative.
During an interview with the Director of Nursing on 8/4/11 at 10:15AM, she revealed that staff should document that education was provided to residents who refuse to be vaccinated.
415.19(a)(1)
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: October 4, 2011
The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Citation date: August 5, 2011
Based on record review and interview, the facility did not ensure that an allegation of verbal abuse was immediately reported to the New York State Department of Health in accordance with State law. In addition, the alleged violation was not thoroughly investigated by facility staff. This was evident for 1 resident reviewed in a sample of 29 residents (Resident #16).
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings are:
Resident #16 has diagnoses including Depression, Congestive Heart Failure and Rheumatoid Arthritis.
Review of the medical record revealed that a MDS 3.0 (an assessment tool) was conducted on 1/21/11 and on 7/6/11. In each of these assessments, a Brief Interview for Mental Status (BIMS) was performed. The resident's score in each of these BIMS was 15, which indicates a top score for the mental status of the resident.
During an interview on 8/05/11 at 2:30PM, Resident #16 stated that a Certified Nurses Aide (CNA) had verbally abused her while she received her shower on the 3:00PM to 11:00PM shift. The resident was uncertain of the day when this incident occurred but stated that it may have happened two to three months ago. During the hour long shower, the resident stated that the CNA berated her. The resident admitted that she was fearful and in tears during this incident. In addition, the resident stated that she was unaware of why the CNA was angry with her.
When the resident was asked if she had reported this incident to the nursing staff, the resident stated she had reported the incident to the Registered Nurse Unit Manager (RNUM), the Director of Social Work (DSW) and her Psychologist.
In an interview with the RNUM on 8/05/11 at 10:35AM regarding this incident, the RNUM stated that she was unaware of this alleged incident of verbal abuse by the CNA towards the resident. No documentation of this alleged incident was found in the nurse's notes of the resident's medical record.
On this same date, 8/05/11 at 10:40AM the DSW was asked if she had knowledge of this alleged incident. The DSW stated that she also did not have knowledge of this incident and that the resident had not reported it to her. Review of the social work notes in the medical record revealed no documentation of this alleged incident.
The resident was able to identify the CNA who allegedly verbally abused her. An interview was conducted with this CNA at 1:40PM on 08/05/11. The CNA was asked if she had ever verbally abused the resident. The CNA denied that she had ever verbally abused the resident and stated that she had no recollection of a verbal dispute with the resident while providing a shower for the resident.
Review of the the resident's Psychologist's service note in the medical record revealed that on 2/14/11 the resident had spoken with the Psychologist about the difficulty that the resident had had with a CNA. The note continued that the resident expressed feelings of fear and worry over the situation. The Psychologist ended her service note by stating that staff was aware of the situation with the CNA.
The resident's Psychologist was interviewed by telephone on 8/05/11 at 2:00PM and asked about her knowledge of this alleged incident of verbal abuse. The Psychologist stated that she could not recall an incident of the resident complaining of verbal abuse by a CNA during a shower. The Psychologist stated further that she often discusses the resident with facility staff but she was not certain as to who she may have discussed the resident's feelings of fear and worry about the situation with the CNA, as she stated in her service note. The Psychologist admitted that she should have written a more indepth note explaining the resident's situation with the CNA at that time.
On 8/05/11 at 12:30PM the resident's allegation of verbal abuse by a CNA and of the facility's lack of reporting and investigation of this incident was discussed with the Registered Nurse Day Supervisor (RNDS). Although the RNDS stated that she was not employed by the facility at the time of this incident, she agreed that the facility should have reported and investigated the resident's allegation.
415.4(b)(1)(ii)
K76 NFPA 101: MEDICAL GAS SYSTEM
Scope: Widespread
Severity: Potential for more than Minimal Harm
Corrected Date: October 4, 2011
Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99 4.3.1.1.2, 19.3.2.4
Citation date: August 5, 2011
Based on observation and interview the facility did not ensure that medical gas is protected in accordance with NFPA 99 in that the main oxygen storage area is being housed in a wooden structure.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
On 8/2/11 at approximately 10:40AM during life safety rounds it was observed that oxygen tanks are being stored in a wooden structure. The total amount of full tanks being stored at the time of this observation was 1976 cubic feet. This structure shares a common wall with a wooden building used to store cardboard boxes and paper supplies. This storage area is located to the side of the facility, less than 25 feet from an exit pathway.
In an interview on 8/3/11 at 2:00PM the Director of Maintenance and Administrator stated that the issue would be addressed.
NFPA 101 (2000 edition) 19.3.2.4
NFPA 99 (1999 edition) 4-5.1.1.2 (b)7, 4-5.1.1.2(b)10a
10NYCRR 711.2(a)(1)
K130 NFPA 101: OTHER
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: October 4, 2011
OTHER LSC DEFICIENCY NOT ON 2786
Citation date: August 5, 2011
NFPA 101 (2000 addition) Section 19.5.2.1 states that heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
NFPA 101 (2000 edition) Section 9.2.1 states that air conditioning, heating, and ventilating ductwork and related equipment shall be in accordance with NFPA 90A.
NFPA 90A Section 2-2.1.1 states that outside air intakes shall be located to avoid drawing in combustible material or flammable vapor.
AIA Guidelines Section 7.31.D3 states that fresh air intakes shall be locate at least 25 feet from plumbing vents.
Based on observation and interview the facility did not ensure that ventilation and air conditioning systems were installed as per Code in that toilet vents were found less than 25 feet from the fresh air intake unit.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
On 8/2/11 at 10:00AM, during life safety rounds it was observed that three sewer vent pipes, located on the roof were situated approximately six feet, eight feet, and five feet away from the fresh air intake unit.
In an interview on 8/2/11 at 10:10AM, the Director of Maintenance stated that it was part of the original design for the building.
NPPA 101 (2000 edition) 19.5.2.1, 9.2.1
NFPA 90A (1999 edition) 2-2.1.1
AIA Guidelines (1996-97 edition) 7.31.D3
10NYCRR 711.2(a)(1)