Morningside House Nursing Home Company Inc

Based on observation, it was determined that the facility did not ensure that the compressor fan covers the "walk-in" refrigerators are maintained free of lint/dust, that the lighting fixtures within the "walk-in" refrigerators and the kitchen areas are protected to prevent broken glass from falling onto food or food contact surfaces and that the floor surfaces within the walk-in refrigerator are clean and free of spills.

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

The findings include:
On November 4, 2010, at 10:00 AM to 11:30 AM during the kitchen tour, the following was observed:

(1) In the "walk-in" refrigerator #1 and #3, the compressor fan covers were noted ladden with sooty lint and dust. The loose lint/dust has the potential to be blown outo the stored food items.

(2) In the "walk-in" refrigerator #3, the electrical conduits leading to the rear of the metal rectangular box containing fans were noted ladden with thick layers of lint/dust of approximately 2 inch long and 1/4 in of multiple strands of loose lint were noted hanging from the conduits. A rolling food stand containing miscellaneous cold sandwiches was noted stored immediately beneath the lint ladden conduits.

(3) The floor surfaces along the perimeter of the "walk-in" refrigerator #2, were noted encrusted with brownish/black dried spills and debris.

(4) In "walk-in" refrigerators #'s 1,2 and 3, the ceiling mounted florescent lighting fixtures were not protected to prevent broken glass from falling onto food or food racks. Although, the lighting fixtures (bulbs) are provided with plastic tube like protective covers, the covers are partially covering the bulbs. Also, the end fastening holders (caps) for the plastic tube coverings are missing. The end fastening holders for the plastic tube coverings are necessary for the covers to be kept in place upon the breakage of the lighting bulbs.

(5) A number of plastic covers on the rectangular ceiling lighting fixtures in the kitchen areas, especially above the deserts/sandwiches production counter, have their end metallic plates coverings dented or not properly fitted so as to create gaps at the extremities. These gaps would not ensure the containment of broken glass within the light covers.

(6) The vertical metallic will molding at the exterior o f the "walk-in" refrigerator #2, is dented to create an approximately 2 ft long and 1 inch wide crack between the wall and the molding. The gap would allow the accumulation of foreign matter between the wall and the molding. In kitchen areas, the walls floors and ceiling surfaces are to be maintained smooth, cleanable and free from cracks and crevices to prevent the possibilities of entry by insects other foreign material.

On November 4, 2010, at approximately 11:30 AM, the facility's director of maintenance stated that all identified items in the kitchen will be corrected and monitored for continuous compliance.

415.29 (j)(1), 415.14 (h)

Based on record review, and staff interviews, the facility did not ensure that the medical record was complete and accurate. Specifically there was no physician orders for routine laboratory blood tests. This was evident 2 of 30 sampled residents (Residents #17 and #23).

This resulted in no actual harm with the potential for more than minimal harm.

The findings are:

1) Resident #23 is an 82 year old with the diagnoses that include Diabetes Mellitus, Hypertension, Dementia, and Legally Blind.

The medical record contained results for the following tests:
1) On 1/20/10 and 4/14/10 a fasting chemistry was obtained for a Basic Metabolic Panel, and a Complete Blood Count.
2) On 4/15/10 a Glycohemoglobin was obtained.
3) On 5/3/10 a Albumin was done.
4) On 5/14/10 a Calcium, Phosphorous .
5) On 7/28/10 a Lipid Panel and Liver Enzymes was done.
6) On 9/10/10 a Basic Metabolic Panel, a Hemoglobin A 1 C and a Complete Blood Count was reported.

There is no documented evidence in the Physician's order dated 1/19/10, 3/15/10, 4/13/10, 5/11/10, 7/6/10 for any of the laboratory results.

An interview with the Registered Nurse (RN) and the Nurse Manager was conducted on 11/9/10 at 1:20 PM. They stated that the NP (Nurse Practitioner) and the physician orders the labs in the computer and when there is an abnormal results the laboratory will call the nurses and they will inform the NP or physician. The nurses are not aware of the lab tests that the NP and/or the physician orders. The nurses don't have access to the computer to see what labs were ordered.

An interview with the Nurse Practitioner (NP) was conducted on 11/9/10 at 1:25 PM. The nurse practitioner stated that the protocol here is that the nurse practitioner puts the lab test to be done in the computer and then will inform the nurse. The nurse only knows if there is a stat order and there is a separate order sheet for urine, stool, or wound specimens/cultures. The nurse practitioner continued to state that we don't put orders for labs tests on the physician's order form. The NP finished by saying "I tell the nurses which labs I put in, the nurses don't have to know".

An interview was conducted with the Director of Nursing and the Medical Director on 11/9/10 at 6:55PM. The Medical Director stated that in the charts there are no orders for labs. Laboratory test are ordered online and that is the official lab order. They continued to state that everybody can go on the computer and get the labs. The Medical Director and Director of Nursing stated they do not understand why the nurses need to know what laboratory test were ordered for the resident.

2.) Resident #17 an 82 years old female admitted to the facility with diagnoses Dysphagia, Hypertension, Urinary Tract infection and Thrombocytopenia.

The medical record contained the laboratory results for the following:
1) On 07/23/2010 - Basic Metabolic Panel.
2) On 07/27/2010 - complete blood count (CBC) with Total protein and Albumin
3) On 09/23/2010 - CBC and CMP (complete metabolic profile)

There is no documented evidence in the Physician's order dated 07/16/2010 to 10/13/2010 for any of the laboratory results.

The RN (registered nurse) was interviewed on 11/8/10 at 5:30pm and stated the nurses cannot access the computer. On further interview , the RN stated - MD orders for laboratories are not written in the charts except when they are stats or telephone orders. The requests for blood tests go directly to the laboratory.

415.22

Based on observation, record review, and staff interviews, the facility did not ensure that the resident's psychotropic medication was reviewed for a gradual dose reduction since the admission in March of 2010. In addition, the facility did not ensure consistent documentation regarding indication for use of psychotropic medication and its effects on the resident's behavior. This was evident for 1 (one) of 30 sampled residents . (Resident # 4)

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

The finding is:

Resident # 4 was admitted to the facility on 3/26/2010 from the hospital. The Patient Review Instrument (PRI) dated 3/24/2010 documented that the resident was hospitalized since 3/20/2010 for UTI (Urinary Tract Infection)/ Fecal Impaction. Her additional diagnoses documented PMH (past medical history) Dementia/ A Fib (Atrial Fibrillation), Recurrent falls/chronic back pain. The active medication profile of PRI documented that on 3/25/10, the resident was placed on Haldol 1mg am/hs (in the morning and at hour of sleep) due to sundowning and on Lorazepam 1 mg PO (orally) bid (twice daily) PRN (as needed) for agitation.

The resident was observed on 11/4/2010 at approximately 10:45 AM during the initial tour in her bed, at 11/5/2010 at 2:15 PM and 4:30 PM in the dining room watching the movies, on 11/8/2010 during lunch meal and at 2 PM and 3:40 PM participating in activities. At 3:40 PM the resident needed direction to her room and politely asked staff to help her. During a brief interview approximately 10 minutes later, the resident expressed satisfaction with recreational activities and needed direction back to the day room. On 11/9/2010 from 3:30 PM to 4 PM the resident was observed engaged in a conversation with a female peer. The resident was not observed with aggressive behavior or with agitation throughout the survey.

The Minimum Data Set (MDS) 2.0 assessment dated 9/29/2010 documented that the resident had short and long term memory impairment with moderately impaired cognition and resisted care 1 to 3 days in last 7 days, but behavior was easily altered. The resident received antipsychotic medication 7 days per week.

Standards of care for resident's care planning (universal standards implemented since July, 2009) include following interventions under- medications: psychotropic drug use " Medication review periodically for dose appropriateness and for possibility of reduction, evaluate for non-pharmacologic, behavioral interventions that may decrease the need for medication. "

The Comprehensive episodic behavioral care plans dated 4/26/10 and 8/16/10 document that the resident verbalizes desire to go home to see her son and seeks exit via elevator. The interventions include reassurance that son will be visiting, engage in conversation, provide emotional support, and engage in recreational activities.

The Physician's admission orders dated 3/27/2010 documented " Haldol 1mg tab (tablet) hs (at hour of sleep) (for) agitation, Ativan 1 mg tab HS PRN (at hour of sleep as needed) for agitation. "

On 3/30/2010 previous order for Ativan was discontinued and replaced with " Ativan 0.5 mg PO (orally) BID (twice daily) PRN (as needed) agitation. "

The physician's orders until 10/31/2010 document no further changes in the psychotropic medication regimen during the period of seven months. The monthly physician's orders dated 10/31/2010 document "Haloperidol tab 1 mg...Haldol...take one tablet by mouth at bedtime (agitation)...Lorazepam 0.5mg -tabs...Ativan...take one tablet by mouth twice daily as needed."

There is no documented evidence of attempted gradual dose reduction (GDR) of psychotropic medication or documented explanation why the GDR was contraindicated .

The physician's periodic visit dated 4/13/2010 documents " Dementia - no psychosis ... "

The physician's monthly assessments from 6/9/2010 until 10/31/2010 document " Psych pleasant and cooperative ... Dementia - Not on meds ...active and good spirited, continue off meds for now ... "

The nurses notes for 4/26/10 documented that the resident adjusted well to the new unit, but was confused and sporadically attempted to go on the elevator, or paced in front of the elevator waiting for her son. The resident was provided with a target watch (to prevent elopement).

The review of the Resident care profile- behaviors and interventions record (completed by the Certified Nursing Assistants) from 6/2010 - 10/2010 documented wandering behaviors daily. The same record for 11/10 documented no behavioral issues. There is no documented evidence of physically or verbally abusive behaviors, physically disruptive or socially inappropriate behaviors.

The Medication administration records documented Ativan given on:
3/27/10, 3/28/10, 3/30/10, and 4/2/10 for agitation and was effective
4/19/10 - no reason for administration or effect documented
5/1/10- 5/31/2010 - not administered
6/18/10 and 6/19/10 administered for agitation and was effective
7/1/10- 7/31/2010 - not administered
8/12/10, 8/16/10, 8/19/10, 8/21/10 administered for agitation and was effective
9/8/10, 9/18/10, 9/21/10, 9/25/10, and 10/31/10 no reason for administration or effect documented
11/3/10, 11/5/10 administered for agitation and was effective .

For 14 out of 18 administrations of Ativan, the medical record does not describe agitated behavior or interventions implemented prior to the administration of medication. For 6 out of 18 administrations, the medical record does not document indication for administration of Ativan or its effect of on the resident.

The pharmacy medication regimen review accountability record documented on 6/25/2010 recommendation for psychiatric evaluation. Full report was requested, but not produced by the facility.

On 11/9/2010 at 1:20 PM the Licensed Practical Nurse #1 on orientation, who was until a few weeks ago employed as a Certified Nursing Assistant (CNA) assigned to the resident in the past described the resident as confused, most of the time very cooperative and pleasant. She stated that the resident was never aggressive or combative, but at times refused shower per schedule.

On 11/9/2010 at 1:30 PM the Certified Nursing Assistant #1 assigned to the resident on dayshift described the resident as " very pleasant woman " , " polite, " " never aggressive. " She stated that the resident is very easy to work with, but is very confused and keeps asking for directions to the bathroom, the dayroom, etc.

On 11/9/2010 at 3:55 PM the Certified Nursing Assistant # 2 assigned to the resident on evening shift described the resident as " calm, responsive to redirection, " and " never aggressive. " The CNA #2 stated that the resident's son visits daily around 5PM and at times the resident paces in front of the elevator or sits in the chairs nearby awaiting for his arrival.

On 11/9/2010 at 4:10 PM the Certified Nursing Assistant #3 was interviewed and stated she knew the resident well as she was assigned to her in previous months. She described the resident as " confused " and " very cooperative." At times, the CNA #3 stated, the resident " refused to brush her teeth " and would state " leave me alone, " but the " gentle talk and encouragement " were always very effective with this resident.

On 11/9/2010 at 2:45 PM the Licensed Practical Nurse #2 was interviewed and stated that she is a regular medication nurse. The LPN #2 described the resident's " agitation " as pacing in front of the elevator, attempting to go on the elevator, and asking for her son. When the LPN #2 tries to redirect her, the resident replies " I don't want you. I want (son's name) to take care of me. " The LPN #2 stated she tries to redirect the resident to the dining room, offers her water, or asks the CNA to walks with her. When this is ineffective, she gives the resident her PRN medication. The LPN #2 stated that the resident is never aggressive, but displays a high level of anxiety and confusion at times. She further stated that the resident's behavior and interventions implemented prior to the PRN medication should be documented, as well as the effect of the PRN medication, but sometimes " it gets very busy and this was overlooked. "

On11/9/2010 at 2:15 PM the Registered Nurse Supervisor was interviewed and stated that the management of psychotropic medications is generally the Medical Doctor's (MD) decision. He stated that he would notify the MD if the psychotropic medication was not effective. The RN Supervisor stated he participates in the interdisciplinary care plan meetings, but could not recall that the resident's medication was discussed. He described the resident as " stable. "

On 11/9/2010 at 2:30 PM the Medical Doctor was interviewed by phone and stated that he was not aware of any psychotropic medication protocol implemented by the facility. He further stated that the interdisciplinary team makes determination regarding the dosage and monitoring of psychotropic medication in relation to the resident's behavior. The MD refused to discussed with the surveyor specifics regarding this resident as he had " nothing in front of him " and " could not speak from memory. "

On 11/9/2010 at 3 PM the Medical Director was interviewed and stated that the facility follows the federal guidelines regarding the administration of psychotropic medication, as well as gradual dose reduction (GDR). Generally, if the resident is stable, a GDR would be attempted. It is at discretion of the attending Medical Doctor to attempt GDR or not. If the GDR is not attempted " there should be physician's documentation to elaborate, why the GDR was medically contraindicated. " The Medical Director concluded " I do not see in the medical notes where that was addressed. "

The Psychotropic Medications Policy of the facility dated January 24, 1999 documents " Residents who use psychotropic drugs should receive gradual dose reduction, drug holidays or behavioral programming, unless clinically contraindicated ...Responsibility (of) Primary Physician 11. Determine if dose reduction is possible and order same, unless clinically contraindicated; 12. If dose reduction is clinically contraindicated, document reason(s) in progress notes. "

415.12 (l)(1)

Based on observation, the facility did not ensure to maintain essential mechanical equipment in a safe and proper operating condition. Reference is made to the leaks observed in boiler
#1, the steam valve, the secondary pump and the 2\'bd-inch condensation return pipe all located in the boiler room in the facility's sub-basement level of the B-building.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the environmental tour conducted on 11/5/10 at approximately 12:55pm, leaks were observed from boiler # 1, the steam valve, the secondary pump and the 2\'bd-inch condensation pipe all located in the boiler room in the facility's sub-basement level of the B-building. Puddle of water was observed on the floor by each of the equipment noted to leak.

In an interview with the Director of Facilities on the same day at approximately 1:00pm, he stated that an outside vendor would be called in to repair the leaks.

415.5(e)(1)(2)

Based on record review and staff interview the facility did not ensure that a resident with a diagnoses of Mental Retardation receive a PASRR (Preadmission Screening and Resident Review). This was evident for 1 of 3 sampled residents for PASRR in a sampled of 30 .Resident # 21.
This resulted in no actual harm with potential for more than minimal harm.
The finding is:
Resident # 21 is a 69 year old male admitted to the facility on 10/18/06 with diagnoses which include Mental Retardation.
The Physicians orders dated 10/25/10 document that the resident has a diagnoses of Mental Retardation.
There is no docuemnted evidence from 2007 - 11/9/10 that the facility obtained a PASRR determination for the resident.
On 11/9/10 the Vice President of Social Services was interviewed and stated that she had placed several calls back in 2007 regarding the PASRR and that she never got a response from the OMRDD (office of mental retardation and developmental disabilities).

415.11(e)

Based on observation, it was determined that the facility did not ensure that exit signs placed perpendicular to travel to the exit stairs are provided with directional indicators that point to the exit doors as per 7.10.6.2.

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

The findings include:
On November 4, 1010 , at 11:00 AM to 2:00 PM, it was observed that the facility has installed exit signs perpendicular to the egress travel at the entrance doors to the exit stairs. The exit signs lack the directional indicators (arrows) pointing to the exit stair doors (examples are: North and South stairs, on the 4th floor in "A" building, and West stair, on the 2nd floor, in the A building, ) On November 4, 2010, at approximately 1:00 PM, the facility's director of maintenance stated that the exit signs will be provided with appropriate directional indicators pointing to the entrance doors to the exit stairs.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the corridor door to room #244, in the "A" building, is maintained to close tightly in its door frame without any impediment.

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

The findings include:
On November 4, 2010 , at 11:00 AM to 2:00 PM, it was observed that the facility has a double leaf door at a resident room that opens to the corridor. The wider door leaf to room #244 was hitting the edge of the shorter door leaf which impeded the door from closing and latching positively. On November 4, 2010, at approximately 12:30 PM, the facility's director of maintenance stated that the door will be adjusted to close without any impediment and latch so as to resist the passage of smoke.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that exit stair "North" enclosure is free from the passage of an overhead drain pipe as per 7.3.3.2.1 and 7.1.3.2.3.

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

The findings include:
On November 4, 2010 , at 11:00 AM to 2:00 PM, it was observed that the North exit stairway enclosure at the lower level (LL), is penetrated by an overhead drainage/sewage pipe of approximately 6 inch diameter. The drainage pipe is not provided with an enclosure of at least 1-hour fire resistance rating. Any accidental water leakage from the drain pipe in the exit stairway would interfere with the safe usage of the stairway by the building occupants during fire or other emergency. On November 4, 2010 at approximately 12:00 PM, the facility's director of maintenance stated that the drainage pipe penetrating the exit stairway enclosure will be enclosed with at least 1-hour fire resistance rating construction.

711.2 (a)(1)

Physical Plant Violation - State Only

The ventilation systems shall be designed and balanced to provide the pressure relationship as shown in Table 8.

This requirement is not met as evidenced by:

Based on observation,it was determined that the facility did not ensur e tha t the ventilation systems for the kitchen areas are maintained to provide a minimum of 2 air changes of outdoor air per hour supplied to the area and balanced to maintain the equal pressure in relationship to the adjoining corridors, as per Table 8.

The findings include:
On November 4, 2010, at 11:00 AM to 2:00 PM, it was observed that the facility has installed an air handling equipment (air supply equipment) for the kitchen areas. The air handling equipment was, however, noted to be not operating upon further investigation . The facility's assistant director of maintenance stated that the unit was turned off for no apparent reason. The facility's engineering staff at that time turned the air handler on. The facility must maintain the air supply equipment in functional order when food preparation is in progress in the kitchen to maintain the equal relationship to the adjacent corridors. On November 4, 2010, at approximately 11:45 AM, the facility director of maintenance stated that the staff will be advised to maintain the functioning of the air handling equipment for the food preparation center at all times.

NYCRR 713-1.18 (d)(2)(v)
All central air ventilation or air conditioning system shall be equipped with filters having efficiencies no less than those specified in Table 9.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the air handling equipment (air supply equipment ) for the food preparation areas (kitchen ) is equipped with 80 percent efficiency filters, as per Table 9.

The findings include:
On November 4, 2010, at 11:00 AM to 2:00 PM , it was observed that the facility has an air supply equipment for the kitchen areas. The air supply equipment is designed to be installed with the bag type filter bed. The bag type filters were, however, missing from the equipment. On November 4, 2010, at approximately 11:55 AM, the facility director of maintenance stated that the HVAC company will be contacted to install the appropriate filter bed in the air supply equipment for the kitchen areas.