Split Rock Rehabilitation and Health Care Center

Physical Plant Violation - State Only

NYCRR 415.29(h)(1)

(h) Ventilating, heating, and air conditioning systems. Such systems shall:

(1) Be maintained in good repair and shall be operated in a manner which will not allow for the spread of infection and provide for resident health and comfort; and

(2) Be maintained and operated in such manner that air shall not be circulated from resident isolation rooms, laboratories in which work is done in pathology, virology or bacteriology, autopsy rooms, kitchen and dishwashing areas, toilet and bath rooms, janitors' closets and soiled utility rooms or soiled linen rooms, to other parts of the facility.

Based on observation and interview it was determined that the facility did not ensure that the air ventilation system was maintained in proper working order. Reference is made to the seven mechanical exhaust motors located on the facility's roof and the mechanical exhaust vents in resident units that were not functioning.

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

The findings are:

During the annual survey conducted on 05/29/12 between 9:00 AM and 3:00 PM, seven mechanical exhaust motors (units # 5, 9, 15, 20, 23, 24 and 29) located on the facility's roof were observed not functioning. Also, mechanical exhaust vents in locations which include but are not limited to the 3rd floor respiratory therapy room opposite room 309 as well as the 4S pantry and soiled utility rooms were not functioning.

In an interview with the Building Services Manager that same day at approximately 10:30 AM, he stated that parts needed to fix the motors would be ordered. However, at approximately 12:10 PM he added that all other motors with the exception of # 9, 23 and 29 had been fixed. He further stated that the mechanical exhaust vents not functioning are connected to the non-functional motors in the roof.

10NYCRR 415.29(h)(1)

Based on observation and interview, it was determined that the facility did not ensure that a clean, comfortable and homelike environment is provided to the residents. Reference is made to:
1) Mechanical exhaust vents that were encrusted with dust.
2) Missing ceiling tiles.
3) Littered resident room floors.
4) Soiled toilet bowls.

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

The findings include but are not limited to:

During the annual environmental tour on 05/29/12 between 9:00 AM and 3:00 PM, the following was observed:
1) The mechanical exhaust vents were encrusted with dust. Examples include (not all inclusive): the bathroom by room 209, 2nd floor pantry and soiled utility rooms, barber's shop on the 2nd floor, 3rd and 4th floor pantries, and 4th floor resident's bathroom by room 415.
2) Missing ceiling tiles were noted in the 1st floor female locker room, room 223, 2nd floor soiled utility room by room 215, housekeeping closet opposite room 225, and the resident's bathroom opposite room 312 (examples not all inclusive). Also, a stained ceiling tile was noted in the bathroom opposite room 318.
3) Resident rooms were observed with litter on the floor, including rooms 431 and 433 (examples not all inclusive).
4) The toilet bowls were observed soiled. Examples include but are not limited to the toilet bowls in room 437 bathroom, resident bathrooms opposite rooms 312 and 421.

In an interview with the Building Service Manager that same day at approximately 11:55 AM, he stated that all items noted will be addressed.

10NYCRR 415.5(h)(1)

Based on observations, record reviews and staff interviews, the facility did not ensure that its medication error rate was less than 5%. This was evident for 3 of 40 opportunities for error resulting in a medication error rate of 7.5% for 1 of 30 sampled residents and for 2 out-of-sampled residents. (Residents #19 , #33, #34)

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

Findings are:

1. During medication pass on 5/30/12 at 8:50 AM, the medication Licensed Practical Nurse (LPN) was observed to administer 10 ml of Keppra (an anti-seizure medication) via a gastrostomy tube (GT) to Resident #19.

A reconciliation of the surveyor's record of observation with the most current physician's order for drugs was conducted. A review of the May 2012 Physician's Order Form revealed that the resident was supposed to receive Keppra 5ml (500mg) via GT every 12 hours.

During an interview with the above medication LPN on 5/30/12 at 9:30 AM, he stated that Resident #19 did not have the above ordered medication available at the time of observation. He stated that he borrowed the medication from another resident (Resident #34) who was also receiving Keppra.

A review of Resident #34's Physician's Order Form dated 5/10/12 revealed an order for Keppra 10 ml (1000 mg) every 12 hours.

2. During medication pass on 5/30/12 at 8:10 AM, the medication LPN was observed to administer three tablets including Norvasc 10 mg. (an anti-hypertensive medication) 1 tablet, Seroquel 50 mg. (an antipsychotic medication) 1 tablet, and Percocet 1 tablet (a pain medication) to Resident #33. The medication LPN then signed the Medication Administration Record (MAR) including two other medications (Lisinopril and Glucophage) which were not observed to have been given at this time.

A reconciliation of the surveyor's record of observation with the current physician's order for drugs was conducted. A review of the May 2012 Physician's Order Form and the current MAR revealed that the resident was also supposed to receive one tablet of Lisinopril (an antihypertensive medication) and one tablet of Glucophage (an antidiabetic medication) daily at 9:00 AM in addition to the above medications.

During an interview with the medication LPN on 5/30/12 at 9:20 AM as to why she signed for and did not administer Lisinopril, she stated that it was not available, of which she admitted that she did not inform the surveyor at the time of the medication pass observation. She had no explanation as to why she signed the MAR. When asked further as to why she signed for the Glucophage without administering it, she stated that "it was just a mistake". She stated that she gave the medication after the surveyor had left.

Further review of the MAR, more than an hour after the medication pass observation, revealed that the nurse's initials on the Lisinopril was not encircled to indicate that the medication was not administered per facility policy and procedure.

415.12(m)(1)

Based on record review and staff interviews, the facility did not fully implement the investigative component of its Abuse Prohibition Protocol to rule out abuse, neglect and mistreatment. Specifically, a thorough investigation was not initiated in a timely manner to determine the cause(s) of pain and swelling sustained by the resident of the left hand which was initially determined to be unknown. Statements from the assigned caregivers were not obtained prior to a final determination that the cause of the pain and swelling on the left hand was medical in nature. This was evident for 1 of 30 sampled residents. (Resident #17)

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

Finding is:

Resident #17 is an 85-year old female who was admitted with diagnoses including osteoporosis, dementia, hypertension and morbid obesity.

A review of the Nursing Notes and Treatment Records form dated 3/6/12 revealed that at 1:00 PM, the resident was noted with swelling to the left hand. The attending physician was notified at this time and ordered an x-ray of the hand.

A review of the Physician's Progress Notes of 3/6/12, 3/7/12 and 3/9/12 revealed ongoing evaluation was conducted by the attending physician and recommended that Doppler studies of the same hand be conducted. No final diagnosis was documented except for swelling and mild edema that were noted on the left hand. A review of the x-ray report dated 3/6/12 revealed no evidence of fracture but showed mild degree of osteoporosis. The result of the Doppler studies was negative as reported on 3/9/12.

When the Director of Nursing was interviewed on 6/1/12 at 11:45 AM, she stated that she does not recall an investigation being initiated. She stated that the cause of the swelling was probably medical in nature and did not warrant further investigation. However, the facility was then able to submit an Occurrence Report dated 3/6/12.

A review of the facility's Abuse Prohibition policy and procedure revealed that interviews may be documented on a Statement Form and the staff may opt to write their own statement or to dictate a statement to the Security investigator. A review of the 3/6/12 Occurrence Report revealed that it did not identify the names of the direct caregivers who were interviewed by the Security investigator nor did it include any verbal or written statements.

When the unit Registered Nurse manager was interviewed at 12:30 PM on 6/1/12, she stated that the resident's condition was discussed during morning report at that time but no documentation was initiated. She stated that it was not until today, 6/1/12, approximately two months later, that she and the nurse assigned on 3/6/12 completed and signed the investigation form.

415.4 (b)

Based on observations and staff interviews, the facility did not ensure that injectable pens or syringes of insulins were stored in accordance with the manufacturer's recommended temperature range to maintain potency and stability. This was evident in 1 of 6 facility units. (3 South)

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

Finding is:

During a tour of the 3 South unit on 5/29/12 at 9:30 AM, it was observed that the temperature of the medication refrigerator, as read by the medication nurse and validated by the surveyor, was 25 degrees Fahrenheit (F). Following this observation, it was noted that there were fifteen (15) injectable pens of Novolog insulin stored inside the refrigerator. The medication nurse stated at this time that she checked the refrigerator at 7:00 AM this morning and found the temperature to be 39 degrees F. She stated that she could not tell how long since this morning that the temperature was at 25 degrees F. She then immediately turned up the control dial to adjust the temperature. She further stated that the temperature must be maintained between 36-46 degrees F.

Further observation was conducted on 5/30/12 at 7:15 AM. It was revealed that the temperature of the medication refrigerator was 30 degrees F. This temperature was again read and validated by the two medication nurses who were present inside the medication room at that time. Both nurses stated at this time that insulins must be stored at temperatures between 36-46 degrees F.

415.18 (d)

Based on observation, record review and staff interviews, the facility did not ensure that the type and size of a tracheostomy (trach) tube in place was in accordance with the physician's order. This was evident for 1 of 4 residents reviewed for trach tube in a sample of 30. (Resident #2)

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

Finding is:

Resident #2 is a 68-year old female who was admitted with diagnoses including status post respiratory failure, tracheotomy, diabetes mellitus and history of pneumonia.

A review of the May 2012 Physician Order sheet for ventilator and tracheostomy revealed an order for Shiley type trach tube size 6. The current Physician's Order Form dated 5/16/12 revealed an order for the same type and size trach tube.

Observation of the resident on 5/29/12 at 2:55 PM revealed that the resident was using a Shiley trach tube size 8. When the Director of the Respiratory Department was interviewed at this time, she stated that the respiratory consultant changed the trach tube on 5/17/12 to size 8. A review of the Physician's Progress Notes dated 5/17/12 revealed that the trach tube was changed but there was no documentation as to the type and size trach tube the consultant had used.

When the assigned Registered Nurse (RN) was interviewed on 5/29/12 at 3:10 PM, he stated that the resident had always used a size 6 Shiley. Upon inspection of the trach tube at this time, the assigned RN stated to the surveyor that he was not aware that the size of the trach had been changed.

415.12 (k)(5)(4)

Based on observation, record review and interview, the facility did not ensure that and treatment were implemented in accordance with the residents' written plan of care and / or physician's orders. Specifically, assistive devices including multi-podus boots and splints were not applied in accordance with the physician's order and that siderails were padded to prevent further injury for a resident with diagnosis of osteoporosis. This was evident for 3 of 30 sampled residents. (Residents #3, #7 and #17)
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
1. Resident # 3 has diagnosis including catatonia, paranoid schizophrenia, status post gastric tube placement, hypertension, and deep vein thrombosis. According to the Minimum Data Set (or MDS; an assessment tool) dated 3/31/12, the resident has impaired range of motion on both sides and both the upper and lower extremities.
A review of the resident's Comprehensive Care Plan (CCP) dated 3/26/12 for contractures indicates that the resident has risk factors to further develop contractures and has actual ankle and elbow contractures, and foot drop. The interventions in the CCP include to prevent further contractures by using bilateral elbow and hand splints to be worn at all times only to be removed every 2-3 hours for skin check and hygiene care. In addition, bilateral multipodus boots are to be worn at all times, and to be removed every 2-3 hours for hygiene care and skin check.
The 2012 May and June Nursing Assistant Accountability Records document that bilateral multipodus boots and bilateral hand splints are to be worn at all times and be removed every 2-3 hours for skin check and hygiene care.
A review of the Physician's Order Form dated 5/17/12 revealed devices to be worn at all times include bilateral multipodus boots, bilateral hand and and elbow splints. These devices are to be removed every 2-3 hours for skin check and hygiene care. The bilateral resting hand splints are to be worn from 8:00 AM - 6:00 PM and be removed every 2-3 hours for skin check and hygiene care.
Multiple observations during the first two days of the survey revealed that the resident did not have the left resting hand splint on and she did not have the two elbow splints on. The resident did not have the multipodus boots on at all but had soft heel protectors. The heel protectors did not remain on the resident's heels but moved constantly to the middle of each leg.
In an interview with the Certified Nursing Assistant (CNA) on 5/30/12 at 9:45 AM after her care with the resident, she stated she did not put on the hand splint because the resident was in pain and she wanted to check to find out if she received her pain medication first. According to the CNA, she was never able to follow up as she was called to the dining room to assist with breakfast. At 10:15AM in an interview with the Licensed Practical Nurse (LPN), the resident received her pain medication at 8AM and the CNA was observed giving care to the resident at 8:30AM by the surveyor.
In another interview 5/30/12 at 10:00AM with the LPN Charge Nurse, she stated she did not know why the hand splint and elbow splints and multipodus boots were not on at the time of this interview. The charge nurse stated she will request a new rehab evaluation for this resident.
2. Resident #7 is a 48-year old male with diagnoses including status post respiratory arrest, deep vein thrombosis and anoxic brain injury.
A review of the current May 2012 Physician's Order Form revealed an order to apply bilateral resting hand splints to be worn 7:00 AM to 7:00 PM and to be removed every 2-3 hours for skin check and hygiene.
Observations of the resident on 5/30/12 at 10:30 AM and at 11:40 AM revealed that the resident had no resting hand splints in place. During an interview with the assigned CNA on 5/30/12 at 11:45 AM, she stated that the resident never had any hand splints since that morning.
During an interview with the Director of Rehabilitation on 5/30/12 at 11:50 AM, he stated that the resident needed hand splints to prevent further contractures. He stated that the hand splints should have been in place per the Occupational Therapist's recommendation.
The unit Registered Nurse (RN) manager was interviewed on 5/30/12 at 11:55 AM. She stated that the resident does not need any hand splints but gave no further explanation when asked about the current physician's order to apply the resting hand splints.
3. Resident #17 is an 85-year old female with diagnosis of osteoporosis, hypertension , dementia and peripheral vascular disease.
A review of the care plan for "At Risk for Accidents/ Falls/ Injury" updated on 4/8/12 revealed interventions including the application of padded side rails to prevent skin tears and prevent injury. A review of the Physician's Order Form dated 5/24/12 revealed and order for bilateral padded 1/2 siderails.
Observations on 5/30/12 at 2:00 PM and on 5/31/12 at 7:40 AM revealed that the resident did not have any padded 1/2 siderails in place.
During an interview with the unit RN manager on 5/31/12 at 8:00 AM as to why there was no padded siderails in place, she stated that the resident does not need them but she did not give any further explanation as to why she would discontinue the use of the padded siderails to prevent skin tears and injuries without proper assessment.
Following the above observation and interviews, the RN unit manager applied bilateral paddings between the resident and the 1/2 siderails on 5/31/12 at 11:00 AM.
415.11(c)(3)(ii)

Based on observation, record review and interview, the facility did not ensure the implementation of the plan of care for a resident who has contractures. Specifically, bilateral assistive devices were not worn at all times in accordance with the Physician's Order for Resident # 3.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The findings are:
Resident # 3 has diagnosis including Catatonia, Paranoid Schizophrenic, Status Post Peg Tube Placement, Hypertension, and Deep Vein Thrombosis. According to the significant change Minimum Data Set (MDS), an assessment tool, dated 3/31/12, the resident's cognitive ability is severely impaired with long and short term memory problems. Her Mood issues determined by the staff indicate that the resident has little interest in doing things, she feels down and tired and has a poor appetite most of the time. The resident's exhibited behaviors are hallucinations and delusions. The resident's range of motion is impairment on both sides and both the upper and lower extremities . The resident's Comprehensive Care Plan (CCP) dated 3/26/12 for contractures indicates that the resident has risk factors to further develop contractures and has actual ankle and elbow contractures, and foot drop. The interventions in the CCP to prevent further contractures requires bilateral elbow and hand splints to be worn at all times only to be removed every 2-3 hours for skin check and hygiene care and bilateral multipodus boots to be worn at all times, and to be removed every 2-3 hours for hygiene care and skin check. The May and June Split Rock Nursing's Assistant Accountability Record documents that Bilateral multipodus boots and bilateral hand splints to be worn at all times and removed every 2-3 hours for skin check and hygiene care. The Physician's Order dated 5/17/12 revealed devices to be worn at all times were bilateral multipodus boots , bilateral hand and elbow splints and removed every 2-3 hours for skin check and hygiene care. Bilateral resting hand splints to be worn from 8AM - 6PM and removed every 2-3 hours for skin check and hygiene care.
Multiple observations during the first two days of the survey revealed that the resident did not have the left resting hand splint on and she did not have the two elbow splints on. The resident did not have the multipodus boots on at all but had soft heel protectors. The heel protectors did not remain on the resident's heels but moved constantly to the middle of each leg.
In an interview with the Certified Nursing Assistant (CNA) on 5/30/12 at 9:45AM after her care with the resident, she stated she did not put on the hand splint because the resident was in pain and she wanted to check to find out if she received her pain medication first. According to the CAN, she was never able to follow up as she was called to the dining room to assist with breakfast. At 10:15AM in an interview with the Licensed Practical Nurse (LPN), the resident received her pain medication at 8AM and the CNA was observed giving care to the resident at 8:30AM by the surveyor.
In another interview 5/30/12 at 10:00AM with the Charge Nurse, an LPN, she stated she did not know why the hand splint and elbow splints and multipodus boots were not on at the time of this interview. The Charge Nurse stated she will request a new Rehab evaluation for this resident.
415.11(c)(3)(ii)

Based on observations and staff interviews, the facility did not ensure that care and services were provided in accordance with standards of professional nursing practice. Specifically, the medication nurse did not check placement of gastrostomy tube (GT) prior to administration of medications, and the narcotic count was not conducted between two licensed nurses at the change of shift to ensure proper accountability and prevent possible drug diversion. This was evident for 1 of 2 residents with GT tube observed for medication pass (Resident #19) and on unit 3 South.

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

Findings are:

1. Resident #19 is a 78-year old male who was admitted with diagnoses including cerebrovascular accident, seizure disorder and a history of acute respiratory failure. The resident is ventilator dependent and was assessed to be at risk for aspiration.

A review of the May 2012 Physician's Order Form revealed that the resident's medications were to be administered via a gastrostomy tube.

During a medication pass observation on 5/30/12 at 8:50 AM, the medication nurse was observed to push 30 ml. of water using a 60 ml syringe into Resident #19's GT tube. The nurse was not observed to check the placement of the GT tube prior to giving the water. The surveyor intervened and interviewed the medication nurse as to the safety procedure to follow prior to administration of any solutions or medications via a GT tube. The medication nurse admitted that he should have checked the tube placement first prior to administration of water to ensure that the end of the tube was inside the stomach.

2. During observation of unit 3 South on 5/30/12 at 7:10 AM, it was noted that an incoming day shift medication nurse was inside the medication room counting narcotics by himself. There was no other licensed nurse present inside the medication room with this medication nurse to witness the narcotic count. This observation was immediately brought to the attention of the unit Registered Nurse manager at this time. She stated that narcotic count should be conducted between two licensed nurses for proper accountability and to prevent possible diversion.

When the above medication nurse was interviewed on 5/30/12 at 8:00 AM, he did not provide an explanation as to why he started counting narcotics without another licensed nurse present.

The facility in-service educator was interviewed at 9:00 AM on 5/30/12. She stated that it is the facility policy and standard of practice that two nurses count narcotics together at the beginning and end of each shift.

415.11 (c)(3)(i)

s

1999 NFPA 99 Chapter 3-4.2.2 Specific Requirements.
Chapter 3-4.2.2.1* General. Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the equipment system.
The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation.
Both systems shall be arranged for connection, within time limits specified in this chapter, to an alternate source of power following a loss of the normal source.
The number of transfer switches, to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW).

Based on observation, staff interview and record review during the recertification survey, it could not be determined that the facility is equipped with a Type I Essential Electrical System (EES) for its ventilator dependent residents in accordance with NFPA 99. This was evidenced by the lack of documentation from the facility that indicates that they are equipped with a type I essential electrical system (EES).

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

The findings are:

During life safety rounds conducted on 05/29/12 between 9:00 AM and 3:00 PM the facility was noted to have ventilator dependent residents on the 3rd floor. It was also observed that the facility was equipped with a generator set which was located on the 1st floor. Upon inspection and inquiry, the facility was unable to provide documentation that showed what type of Essential Electrical System (EES) they are equipped with or to indicate that they are equipped with a Type I EES that is required for facilities with ventilator dependent residents as per NFPA 99.

A tour of the emergency generator/electric room (located on the first floor) and an interview with the Maintenance Director revealed that the generator is equipped with one transfer switch only that serves the nursing home building.

In an interview with the Building Service Manager that same day at approximately 1:50 PM, he stated that he would try to locate the document requested. Furthermore, in a separate interview the same day at 2:25 PM, the Administrator stated that he would also try to secure the requested documentation. However, as of 6/1/12, the facility was still unable to present the requested documentation.

10NYCRR 713-1.19(a)(1)
1999 NFPA 99: 3-4.2.1.4, 3-4.2.2
10NYCRR 415.29

Based on observation and interview, it was determined that the facility did not ensure that egress corridors are kept free of storage which may interfere with the safe usage of the exit corridors during fire or other emergency. Reference is made to the storage of resident, nursing, and housekeeping equipment in resident unit corridors on floors 2, 3, and 4.

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

The findings are:

During the LSC inspection conducted on 05/29/12 between 9:00 AM and 3:00 PM, combustible items were observed stored and unattended in the resident unit egress corridors on the 2nd , 3rd and 4th floors. Items noted stored in the corridors included but are not limited to: Geri chairs, wheelchairs, Hoyer lifts, walkers, housekeeping carts, nursing carts, clean and soiled linen carts.

In an interview with the Building Services Manager that same day at approximately 1:10 PM, he stated that the facility would need to find new storage locations for the equipment observed stored in the corridors on the nursing units.

2000 NFPA 101 - 7.1.10.1
10NYCRR 711.2(a)(1)