Bronx Center for Rehabilitation & Health Care

Based on observation and staff interview, the facility did not ensure that expired drugs were disposed of and removed . This was evident on 1 of 5 units (Unit 3) .

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

The finding is :

During the initial tour of the third floor on 08/29/2011 at 10:30 AM, several vials of medications were observed in the medication refrigerator with expired dates and undated specifically :

1.) One (1 ) vial of Tuberculin Purified Protein Derivative ( PPD ) .This vial was opened and undated, not indicating when it was opened .

2.) Two ( 2) vials of Lantus Insulin were opened with dates written as 07/23/2011 and 07/13/2011 respectively .

3.)Three (3) vials of Lantus Insulin were opened and undated, not indicating when they were opened .

The RN ( Registered Nurse ) Unit Manager was immediately interviewed and stated " the nurses are responsible on checking the dates of the vials every day ". She further stated "how did we missed this ".

The manufacturers package insert on PPD states " a vial of PPD which has been opened and in use for 1 month should be discarded because of oxidation and degradation may have reduced the potency ".

The manufacturers package insert on Lantus Insulin states " opened vials whether or not refrigerated must be used within 28 days . They must be discarded if not used within 28 days ".

Based on observation, record review and staff interviews, the facility did not ensure that each residents' written plan of care was implemented . This was evident for 3 of 30 sampled residents . Specifically :
1. ) Physician's order for a pacemaker check . Resident # 2
2.) Physician's Order for Fingerstick Sliding Scale . Resident # 22
3. ) Physician's order for a supplement . Resident # 25 .

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

The findings are:

1. ) Resident # 2 is a 66 year old male admitted to the facility with diagnoses including: Cardiomyopathy , Hypertension, Heart Failure , Diabetes Mellitus , Esophageal Reflux and Gait Abnormality.

Resident was observed in his room , alert and verbally responsive. Resident answers appropriately to questions.

The minimum data set 3.0 assessment dated 06/29/2011 identified the resident as cognitively intact with BIMS ( brief interview for mental status ) score of 12 .

The physician's order dated 06/16/2011 , 07/14/2011 and 08/11/2011 documented : pacemaker check as per protocol. However, review of the medical records reveals no evidence that the pacemaker check was done .

During an interview with the charge RN ( registered Nurse ) on 09/02/2011 at 2:25 PM she stated " I remember that he refused it initially , then it was reordered by the physician and I can only say it was not done again because I overlook it. I know I should have done a follow up ".

The physician was interviewed on 09/02/2011 at the same time and stated " resident is stable but would like to have his pacemaker monitor while in the facility ".

2. Resident # 22 is a 80 year old female with the diagnoses including : Diabetes Mellitus, Hypertension, and Bacteremia.

The Minimum Data Set 3.0 (MDS) dated 7/12/11 documented BIMS (Brief Interview Mental Status) score as 7 which indicates resident #22 cognition as severly impaired.

The Physician's Orders dated 8/9/2011 documented, "FS BID with ASPART SS/ < (less than) 80 > (greater than) 400 INFORM MD"

The Medication Administration Record (MAR) dated August 2011 revealed on August 20 at 5 PM resident's FS was 402 mg/dl (miligram per deciliter). Resident was given 6 units of insulin. There is no documented evidence that the physician was informed.

The Registered Nurse (RN) manager was interviewed on 9/2/2011 at 12:45 PM. The nurse manager stated the process is the nurse would notify the evening supervisor and then the evening supervisor would call the physician and find out what to do next. The nurse manager continued by stating, "there is no indication that was done." The nurse manager stated that there is no progress note and it is not documented on the twenty four (24) hour report then she assumes the supervisor was not notified.

3.) Resident # 25 a 81 year old female admitted to the facility with diagnoses including : Chronic Airway Obstruction, Congestive Heart Failure , Diabetes Mellitus , Asthma , Hemiplegia , Dementia and Epilepsy .

The minimum data set 3.0 assessment dated 06/14/2011 identified the resident as severely impaired with cognition. Regarding activities of daily living, she is totally dependant to facility staff.

The physician's order dated 08/08/2011 documented Prostat 64 1 oz ( ounce ) BID ( twice a day ).

Review of the MAR ( medication administration record ) and the TAR ( Treatment administration record ) from 08/09/2011 to 09/01/2011 revealed no documented evidenced that the Prostat as prescribed by the physician was administered .

The medication LPN ( licensed practical nurse ) was interviewed on 09/02/2011 at 11:45 AM and stated " I gave all her medications that are listed on the MAR and I don't see Prostat written . I did not give it " .

The Registered Nurse unit Mananger was interviewed on 09/02/2011 at 12:00 PM and stated " I reviewed the MAR and TAR and I cannot find any record of the Prostat as given . The MD ( medical doctor ) orders are transcribed by the Unit Licensed Nurses , reviewed and signed off on all shift . I cannot explained what had happened , but I will make sure it will be started today" .

The facility policy on transcription of physician's order documented : The licensed nurse is responsible for transcribing orders written by the Physician . Physician's order are to be transcribed /processed into the appropriate record exactly as written and are not to be altered. All orders once transcribed must reflect the date and the signature of the nurse who transcribed the orders.
NURSES ON NEXT TWO SHIFTS MUST REVIEW THE ORDERS FOR ACCURACY IN TRANSCRIPTION, AND DATE /SIGN THE ORDERS.

415.11 (c)(3)(ii)

Based on observation and interview it was determined that the facility did not ensure that all means of egress were maintained so that the exit and exit access is readily accessible at all times. This was evidenced by vehicles parked outside the Physical Therapy/Occupational Therapy area(PT/OT). Also,laundry room doors in the basement were installed with dead bolt locks.

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

The Findings are:

On 08/30/11 and 08/31/11 an Annual Recertification Survey was conducted and the following observations were made:

(a) On 08/30/11 at approximately 10:25 AM, the Physical Therapy area was surveyed and an "EXIT" signage was observed that lead to public way (Underhill Avenue). Three vehicles were observed parked in very close proximity to the exit door that impeded the full and instant use of this exit pathway to a publc way.

In an interview with the Director of Housekeeping on 08/30/11 he stated that he will ensure to keep this path free of all impediments so as to maintain a smooth and unimpeded passage way.

(b) On 08/30/11 at approximately 11:38 AM, during the basement tour with the housekeeping director, the laundry area was visited and it was observed that three (3) dead bolt locks were installed on three separate doors in that egress from the doors will be impossible to open if the locks were engaged from the outside.

In an interview with the Housekeepiong Director on 08/31/11 he stated that all deadbolt locks were already removed from the doors.

NFPA 101 LSC (2000 edition) 7.1, 7.2.1.5.1; 19.2.3.3
NYCRR 711.2 (a) (1)
10 NYCRR 415.29

Based on observation and interview it was determined that the facility did not ensure to indicate the way to an exit access in that no directional sign(s)was or (were) provided from the large storage area (maintenance,dietary,housekeeping) to an egress access in accordance with Section 7-10. This was observed in the basement of the building.

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

The Finding is:

On August 30,2011 at approximately 11:30 AM, during the Annual Recertification Survey, it was observed that the facility did not provide exit directional sign(s)from the large housekeeping, maintenance and dietary storage area located in the basement that will direct occupants in the storage room to the corridor.
In an interview with the Housekeeping Director on 08/30/11 at approximately 11:30 AM, he stated that exit signs will be placed immediately in the required areas.

2000 NFPA 101 LSC; 19.2.10, 7.10
10 NYCRR 711.2; 415.29.

Based on observations and interview it was determied that the facility did not ensure that various sprinkler heads were maintained free of dust and foreign matter. This was observed in multiple resident floors in the facility.

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

The findings include, but are not limited to the following:

On August 30, 2011 during the recertificaiton survey conducted between the hours of 10:00 AM and 2:45 PM, sprinkler heads in the following areas were observed with dust or/and foreign matter:

In the 2nd floor dining room multiple sprinkler heads were observed with dust and in resident room 215,a thread was observed hanging from the sprinkler head.

Three (3) sprinkler heads in the recreation area on the 1st floor were observed with dust/foreign matter.

Multiple sprinkler heads on the 5th floor dayroom were coated with dust.

Three (3) sprinkler heads outside the recreational area and opposite the barber/beauty shop on the 1st floor were observed with dust/foreign matter and sprinkler heads in the laundry room were coated with approximately 1/4 inch of lint.

In an interview with the housekeeping director on 08/31/11 he stated that all sprinklers will be cleaned and maintained dust/foreign matter free. Maintenance department started to clean the sprinkler heads immediately.

711.2 (a)(1)
NFPA 101: 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5