Morningside House Nursing Home Company Inc

Based on observation, record review and staff interviews, it was determined that the facility did not supervise a resident during a dinner meal who is totally dependent on staff for eating. Subsequently, the resident spilled a bowl of hot soup on her right thigh and sustained second degree burns. This was evident for 1 of 30 sampled residents (Resident #7)

This resulted in actual harm that is not an immediate jeopardy.

The finding is:

Resident #7 is a 86 year old female with diagnoses which includes Dementia, Alzheimer's disease, Osteoporosis, and Degenerate Joint Disease.

The Comprehensive Episodic Care Plan dated 1/10/2011 documents "... Pushes food from table." The approach/plan of action documented was to "...Monitor behavior Report changes Involve family in care." There were no further interventions documented for this behavior until 10/5/11.

The Resident Care Profile Plan/Accountability dated 1/11 to 4/11 did not document that the resident "pushes food from table."

The nurses' notes dated 4/22/11 to 10/4/11 did not document any evidence of the resident "pushes food from table."

The MDS (Minimal Data Set) 3.0 dated 9/10/2011 documents that the resident has severe cognitive impairment and for eating is totally dependent on one person physical assistance. This MDS further documents that for locomotion on the unit, the resident is totally dependent on one person physical assistance.

On 11/10/11 at 10 am, the resident was observed sitting in a gerichair in the dining room asleep.

On 11/15/11 at 10 AM, during the dressing change, three burn areas were observed on the resident's right thigh. One burn area measured approximately 3.5 cm (length) x 3.5 cm (centimeters) (width). A second burn area measuring 1.5 cm x 1.5 cm and a third burn area scab measuring 1.5 cm x 1.5 cm.

The Resident Care Profile Plan/Accountability (Certified Nursing Assistant Accountability Record) dated 10/11 (initiated 9/30/11) documents that for eating, the resident is totally dependent and requires the assistance of one person. Additionally, this plan documented that the resident does not ambulate and uses a gerichair. This plan documented that the resident's behaviors are resistive to care, physically abusive, yelling, screaming and hitting staff. This plan does not document that the resident has a behavior of grabbing or pushing food off the dining room table.

The QA (Quality Assurance Investigation) investigation form dated 10/5/2011 documents "...At about 5:30 PM a tray was placed in front of pt. (patient) with her food. Pt. took the soup bowl and turned it on her thigh...."

The nurses' note dated 10/5/11 at 5:30pm documented "Received resident in the dinning room on recliner chair, alert and responsive, but very confused. At about super time, Pt. (patient) reached out and took a bowel of soup and inadvertently spilled it on her thigh, when assessed no redness or visible injury noted at this time. At about 8pm the CNA (Certified Nurse Assistant) called to my attention ADL (Activities of Daily Living) care, blister noted on the right thigh about 4x6x0cm (centimeters). NP (Nurse Practitioner) made aware..."

The Comprehensive Episodic Care Plan dated 10/5/11 documents " .........Behavior of grabbing food.....Discourage behavior....Offer pleasure finger foods."

The medical note dated 10/6/11 documented "Pt c (with) burn and open blister R (right) thigh 2 (secondary) spilling hot soup..."

The medical note dated 10/13/11 documented "ATSP (asked to see patient) for R thigh and open blisters...Skin R thigh c large wound to thigh s/p (status post) Blister open - now c Slough 100% 5x5cm....R side of that blister is small open area 0.6x0.6cm pink..."

The "Internal Quality Assurance Document" dated 10/13/11 documented " ... a burn with blisters to her Right thigh subsequent to the resident spilling hot soup on herself during the dinner meal on 10/5/11 ..." This document further stated that "...She is alert and oriented to person only. She is unable to follow simple commands. She is total assist of 2 for all ADL's (activities of daily living), and is spoon fed. She is often restless, grabbing at food or nearby staff..."

The Summary Of Incident And Investigation dated 10/13/11 documented "...According to staff interviews, she was seated next to a resident who is able to feed himself, and to whom dinner had been served, and across from a resident who feeds herself and to whom dinner had been served. Staff was in the process of serving dinner trays or feeding other residents. It is unclear whether or not (name of resident) had been served dinner as she is in the habit of grabbing other resident's food and dropping it to the floor. In a statement made by the RN, (name of Registered Nurse) she states she was feeding a resident across the room and saw (name of resident) pick up the bowl of soup. She was unable to reach the resident in time to prevent her from spilling the soup. Other staff report that they were involved in either serving or feeding other residents and became aware of incident only after it had occurred. The RN performed an immediate assessment of the (name of resident) right thigh and noted no redness or injury ... At approximately 8:00p.m. when the resident was being put back to bed, the primary nurses' aide reported that she noted blisters to the resident's thigh, and called (name of RN). The conclusion documented was "... It appears the cause of burn was the spillage of soup and that it was accidental, caused by the resident grabbing at a bowl of soup as was her pattern of behavior..."

The medical note dated 10/14/11 documented "Fup (follow up) wounds Pt c Wounds R thigh 2 Burn ... R thigh wounds 1 large wound Open c 100% soft slough 5.2x6.1cm...2 smaller wound c 100% slough soft 2x1.5cm...3 small open wound pink o (no) slough..."

On 11/10/11 at 12PM, the unit Registered Nurse manager was interviewed and stated that the resident has behaviors of grabbing other residents' foods but it is not documented on the CNA (Certified Nurse Aide) accountability record. She further stated that the management of resident behaviors should be documented in the care plan and instructions given to CNA's on the CNA accountability record.

On 11/15/11 at 9:30AM the Director of Nursing was interviewed and stated that the burn was not reported (to the Department of Health) because it was self inflicted. The Director of Nursing stated that this resident has a behavior of grabbing food. Additionally, the resident's tray should not be placed in front of her until the staff is ready to feed her. She further stated that these interventions should be documented in the care plan and CNA(certified nursing assistant) accountability record.

On 11/15/11 at 10:30AM the 3-11PM charge Registered Nurse was interviewed and stated that she did not know who gave the resident a meal tray. The Registered Nurse stated that the plan was to feed her and not seat her with other resident's. However, on the date of the incident, the resident was seated at a table with other residents who feed themselves.

On 11/15/11 the assigned CNA on the 3-11PM evening shift was interviewed and stated that "I was assigned to the resident that day (10/5/2011). I would normally feed the resident but ... I was with another resident. I do not know how she was able to get the bowl of soup. She normally would not sit with other resident's because she is known for grabbing..."

415.12(h)(1)(2)

415.12(h)(1)

Based on record review and staff interviews, the facility did not ensure that comprehensive care plans were revised for residents identified as high risk for falls (Residents #15, #22 and #24). This was evident for 3 of 30 sampled residents. Residents #15, #22 and #24.

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

The findings are:

1) Resident # 15 is a 73 year old male with diagnoses which include status post (s/p) Cerebrovascular Accident (CVA) with Hemiparesis, Hypertension, Vascular Dementia and Seizure Disorders.

The Minimum Data Set (MDS) 3.0 dated 8/9/11 documented resident's Brief Interview for Mental Status (BIMS) score of 7 on a scale indicating severe impairment in cognition. The MDS further documents the resident has unclear speech and disorganized thinking.

The Fall Risk Assessment dated 5/9/11 through 7/30/11 documented resident is at risk for falls. The Fall Risk Assessment dated 8/1/11 and 8/29/11 through 10/30/11 documented that the resident is at high risk for falls.

The Comprehensive Care Plan (CCP) dated 5/9/11 documented "Potential for falls secondary to diagnosis CVA (Cerebrovascular Accident) with Hemiparesis, Hypertension and Vascular Dementia...to be free from falls and to be free from injury". The CCP dated 7/30/11, 8/1/11, 8/24/11, 9/10/11, 10/23/11, 10/29/11 and 11/4/11 documented resident observed on the floor. There is no documented evidence that the CCP was revised with new interventions to prevent further falls.

The Licensed Practical Nurse (LPN) was interviewed on 11/10/11 at approximately 11:00 AM and stated that the nurse manager is responsible for updating the care plans.

The Registered Nurse Manager was interviewed on 11/10/11 at 11:30 AM and stated that she is responsible for updating the care plans and that this resident is monitored closely to ensure his safety. She further stated that the CCP should have been revised.

2) Resident # 22 is a 96 year old female with diagnoses which include Hypertension, Dementia with severe agitation and Depressive Disorder.

The Minimum Data Set (MDS) 3.0 dated 8/19/11 documented resident's cognitive status as moderately impaired with short and long term memory loss.

The Fall Risk Assessment dated October 2010 through August 2011 documented resident is at risk for falls.

The Comprehensive Care Plan (CCP) dated 06/28/10 documented; "Resident will ambulate safely, See Standard of Care". The Episodic CCP dated 12/01/10 documented "Resident was observed on floor....Resident will have no injuries or falls x 90 days....Keep resident in Staff view, Praise efforts, Encourage resident to use walker for ambulation and staff to supervise and redirect as needed". The Episodic CCP dated 5/14/11 documented resident was observed sitting on floor. The Episodic CCP dated 6/1/11 documented that resident fell while walking to her room.
There is no documented evidence that the CCP was revised with new interventions to prevent further falls.

The Registered Nurse was interviewed on 11/16/11 at 10:45 AM and stated that if a resident is identified at risk for falls that they implement the Standard of Care for Falls which is reflected on the Resident Care Profile (Certified Nursing Assistant Accountability). She further stated that if the Standards of Care do not work then they implement an individualized care plan for that resident otherwise they don't initiate a CCP for falls.

3) Resident # 24 is a 75 year old female with diagnoses which include Dementia, Depression and Diabetes Mellitus (DM).

The Minimum Data Set (MDS) 3.0 dated 10/17/11 documented resident's cognitive status as moderately impaired with short and long term memory loss.

The Fall Risk Assessment dated January 2011 through August 2011 documented resident is at risk (high) for falls.

The Comprehensive Care Plan (CCP) dated 1/28/11 documented "1/19/11- Fall, hx (history)of fall-Vision Impairment dx (diagnoses cataract)....Resident will be free of injury x 90 days..." The Episodic CCP for Falls dated 1/19/11 documented "Found sitting on the floor....Continue to remind to take precautions when sitting down, assist if necessary". The Episodic CCPs dated 3/15/11, 4/30/11, 5/2/11, 6/7/11, 9/18/11, 9/20/11 and 9/27/11 documented resident was observed on floor. There is no documented evidence that the CCP was revised with new interventions to prevent further falls.

The Registered Nurse was interviewed on 11/16/11 at 10:45 AM and stated that if a resident is identified at risk for falls that they implement the Standard of Care for Falls which is reflected on the Resident Care Profile (Certified Nursing Assistant Accountability). She further stated that if the Standards of Care do not work then they implement an individualized care plan for that resident otherwise they don't initiate a CCP for falls.

415.11(c)(2)(i-iii)

Based on observation and interview it was determined that the facility did not ensure that all means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 7.1.10 in that storage of numerous items were noted in the resident unit corridors.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

During the LSC inspection conducted from 11/09/11 to 11/15/11 between 9:00am and 3:00pm, storage of items which includes wheel chairs, medication carts, linen carts, Hoyer lifts, large weight scales and chairs were observed stored along resident unit corridors in floors 2, 3, 4, and 5 of the 'A' building and 2, 3 and 4 of the 'B' building. Seven porters cleaning carts and eight large clean linen carts were observed stored in the basement corridor in building A. Storage noted in the corridors would impede or obstruct movement/ use in a case of emergency.

On 11/09/11 at approximately 12:10pm the Director of Facilities stated that the issue with items being stored on the corridor would be brought to the attention of administration.

NYCRR 711.2(a) (1)

1)
(j) Housekeeping

(1) The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, shall be clean. The facility shall be maintained in good repair including, but not limited to buildings, utilities, fixed equipment, resident care equipment and furnishings.

Based on observation and staff interview during the recertification survey, it was determined that the facility did not ensure that it is maintained clean. Reference is made to dusty mechanical vents, peeling paints and ripped base boards noted in various locations.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 11/09/11 to 11/15/11 between 9:00am and 3:00pm, the following was observed:
Dusty mechanical vents in 2nd floor clean utility room - A214, in the 2nd , 3rd and 5th floor soiled linen rooms in the 'A' building and in the elevator machine room in the roof section of this building. Examples are not all inclusive.
Peeling paint was noted in the 'A' building in rooms 240, 241, 'B' building room 352. Peeling wall and ceiling paint were noted in the kitchen dishwashing section. Examples are not all inclusive. Ripped baseboard was observed in room A241. Dirty floor tiles in the 2nd floor clean utility room in the 'B' building.
Kitchen walk-in refrigerator (cook's box) and walk-in freezer were observed with ripped plastic curtains.
Although a floor drain was provided, poodles of water were observed on the floor in the kitchen dish washing section.
Rusty wall paint was noted by the hand washing sink in the pot and dish washing sections of the kitchen.

In an interview with the Director of Facilities on 11/15/11 at approximately 11:20am, he stated that all environmental issues noted would be addressed and that some of them had already been addressed.
415.29 (j) (1)

2)
NYCRR 713-2.22(g)(1)
Based on observation and staff interview, it was determined that the facility did not maintain the resident call system as required in 713-2.22(g)(1) in that:
1) Calls failed to activate a visible signal in a corridor intersection, the pantry, clean utility and soiled utility rooms.
2) No call panel was provided in the 3rd floor pantry room in the 'B' building.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the annual survey conducted from 11/09/11 to 11/15/11 between 9:00am and 3:00pm it was observed that when call bell buttons in various resident rooms were tested, they did not activate visible signals in the following locations -
Rooms - A214, A403, A414, A503 (clean utility rooms), A402, 3rd floor clean utility room, 2nd , 3rd and 5th floor pantry rooms, the 2nd floor soiled utility room and in the corridor by the nurses' station all in the 'A' building. In the 'B' building, this issue was observed in the 2nd floor intersection. Also no call bell panel was provided in the 3rd floor pantry room in the 'B' building.

On 11/09/11 at approximately 12:10pm the Director of Facilities stated that call bell checks would be included in the PM schedule. He added that he would call the call bell vendor to fix all issues noted with the call bell.