Brooklyn United Methodist Church Home

Based on record reviews, and staff interviews, the facility failed to ensure that each resident received the necessary care and services in a timely manner as evidenced by: 1) failing to ensure that residents' on anticoagulant therapy (Coumadin) were consistently monitored when the residents' PT/INR ( Prothrombin/International Normalized Ratio) was non-therapeutic (critical value) which resulted in the residents being hospitalized for Coumadin toxicity (Residents #11, #52, #53, #55 and #57).

This was evident for 3 of 24 sampled residents and 4 of 9 residents in the the expanded sample (Residents #11, #14, #22, #52, #53, #55, and #57).

This resulted in actual harm that is Substandard Quality of Care for Residents #11, #52, #53, #55, #57 and no actual harm with potential for more than minimal harm that is not immediate jeopardy for residents #14 and #22.

The findings include but are not limited to:

1) Resident #52 a 94 year old female admitted to the facility with diagnoses which include: Alzheimer's, Hypertension, Hyperparathyroidism, Osteoarthritis, Anemia, Deep Vein Thrombosis (DVT), and on Coumadin therapy (a drug that is a blood thinner which reduces the formation of blood clots).

The Minimum Data Set 2.0 Assessment dated 10/30/09 identified the resident as severely impaired with cognition, and requires total care with activities of daily living.

The physician orders dated 9/5/09 documented to discontinued Coumadin 4 mg (milligrams), give Coumadin 5 mg at HS (at bed time) and repeat PT/INR (Prothrombin/International Normalized Ratio is use to determine blood clotting) on Monday 9/7/2009.

There is no documented evidence of PT/INR results were obtained on 9/7/09.

The monthly physicians' orders dated 9/10/09 documented that the PT/INR is to be done weekly every Wednesday.

The nurses' note dated 9/12/09 documented the PT result was 11.2 (the reference range is 9.9 to 12.9 seconds) and the INR result was 0.92 ( the reference range is 2.0 to 3.0 ratio). This note further documented that the physician was notified and increased the Coumadin to 6mg.

The physician order dated 9/12/09 documented Coumadin 6mg and PT/INR on Monday 9/14/09.

The PT/INR results dated 9/14/09 documented that the PT was 17.4 and the INR was 1.93.

There was no documented evidence that the resident's non-therapeutic INR of 9/14/09 was addressed.

There was no documented evidence that the PT/INR was completed on 9/18/09 and 9/25/09.

There was no documented evidence in the medical record that the PT/INR was done on 10/2/09.

The Comprehensive Care Plan (CCP) for anticoagulant use/potential for bleeding and brusing dated 10/3/09 documented interventions including: "Monitor for signs and symptoms of bleeding..., and notify physician of abnormal findings... Monitor lab value per MD (Medical Doctor) order,... PT/INR, And notify MD of abnormal values. Monitor effectiveness of anticoagulation therapy and adjust medication accordingly..." The outcome evaluation dated 10/3/09 documented "Resident continue on Coumadin 3 mg by mouth at HS for DVT. No signs of bleeding, CCP ongoing, also PT/INR..."

The (7-3 shift) Licensed Practical Nurse (LPN) progress note dated 10/4/09 documented "Resident alert & (and) responsive to all stimuli called by CNA (Certified Nurse Assistant) to resident room at 12:30P.M. to observed diaper Saturated c (with) bright red drainage Called supervisor to evaluate. T (temperature) - 98.1 - 76 - 18 BP (Blood Pressure) 100/60 O2 Sat (oxygen saturation) 93% - Blood Glucose 99 mg/dl (milligram per deciliter). (Name of) physician notified, transfer resident to (name of) hospital."

The hospital PT/INR results dated 10/4/09 at 1733 (5:33 p.m.) documented INR was > (greater than) 12 with the reference range of 0.86 to 1.12 and PT was > 240 with the reference range of 9.60 to 13.10.

The nursing note dated 10/19/09 at 6 p.m.documented "Res (resident) was readmitted to the facility... New Dx (diagnosis) of Coumadin Toxicity, Vaginal Bleed (resolved), S/P (Status Post) IVC (inferior vena cavae) filter placement ... Skin c (with) multiple ecchymotic areas on bil (bilateral) arms + (and) inner aspect of thighs. MD informed continue previous orders. PT/INR for Wednesday..."

The physician's order dated 10/19/2009 at 9:05 p.m. documented Coumadin 3 mg 1 tab (tablet) at HS. Repeat PT/INR on 10/23/2009.

The nursing note dated 10/24/09 documented "lab result INR 1.27. MD notified and ordered to continue coumadin 3mg h.s and repeat PT/INR on Monday (10/26/09)."

The physician's order dated 10/24/2009 documented to repeat PT/INR on 10/26/2009.

The PT/INR report dated 10/26/2009 documented PT was 19.1 and the INR was 2.27.

The PT/INR report dated 10/28/2009 documented PT was 24.5 and the INR was 3.44.

The physicians' orders dated 10/30/09 documented Coumadin 2.5mg by mouth and repeat PT/INR on Monday, 11/2/09

There is no documented evidence that a PT/INR was completed on 11/2/2009.

The PT/INR results dated 11/4/2009 documented PT was 45.8 (reference range 9.9 to 12.9 and the INR was > 10.0. This report documented that the specimen was collected on 11/4/09 at 6:15 AM and faxed to the facility on 11/4/09 at 16:28 (4:28pm).

The Registered Nurse note dated 11/4/2009 at 7:25 p.m. documented "... attendants arrived on the unit for transfer of resident to (name of) hospital because of elevated INR of >10 which was called in from the... (name o ) lab. (Name of doctor) was informed earlier + requested that resident be transferred out for Coumadin toxicity...She was taken out via stretcher at approximately 7:30 p.m..."

The nursing note of 11/10/09 at 9 p.m. documented that the resident was readmitted to the nursing home from the hospital.

The physician's untimed note dated 11/12/09 documented that the resident was readmitted from the hospital with a diagnosis of Coumadin toxicity.

During the interviews with LPN (Licensed Practical Nurse) #2 was interviewed on 2/26/2010 at 2:00 p.m. and stated that the results of the labs are fax to the facility. If there are critical values the laboratory will call and speak with the Registered Nurse (RN). The LPN stated that it is the RN's/RN (Registered Nurse) Supervisors' responsibilities to distribute the laboratory results, and to call the physician when there are critical values. Further interview with LPN #2 on the third floor unit with regards to the system of transcribing physician's orders, she stated: the LPN will pick up the physician's orders. The monthly labs are carried out by the 7-3 shift. If a resident has a weekly blood test, the 11-7 LPN fills out the form. She illustrated it by saying, a resident with an order of PT/INR weekly, the name is written on a list that is posted in the nursing station. The 11-7 LPN completes the slip the night before the lab test is due. The laboratory technician comes in the morning and takes all the residents' lab work due for that date.

On 2/26/2010, the Laboratory Supervisor (Lab #1) was interviewed by phone and stated that he did not have any record of blood test for PT/INR for the dates of 9/18/2009 and 9/25/2009.

During interviews with the Registered Nurse Supervisors (RNS #2, #3, #4, and #5) during the survey from 2/22/09 through 3/8/10, all stated that it is their responsibility to distribute the laboratory results and if there are critical values, to call the physician.

2) Resident #11 is an 87 year old male re-admitted to the facility on 2/9/10 with diagnoses that include Coumadin Toxicity, Atrial Fibrillation, Hypertension, and Congestive Heart Failure. On 3/2/10 the resident was re-admitted with a diagnoses that included Mental Status Changes and Sepsis.

The Minimum Data Set (MDS) 2.0 Assessment dated 1/8/10 documented that the resident is moderately impaired for cognitive skills for daily decision making, and requires total care for activities of daily living.

The Comprehensive Care Plan (CCP) for Anticoagulant use/Potential for Bleeding and Bruising initiated on 1/09 and evaluated on 4/09, 7/09, 10/09, 1/10, and 4/10 documented the following interventions to "Monitor for signs and symptoms of bleeding and notify physician of abnormal findings; Monitor lab value as physician ordered (...PT/INR- Prothrombin/International Normalized Ratio, blood clotting indicators) and notify physician for abnormal values; and Monitor effectiveness of coagulation therapy and adjust medication accordingly."

The physician's order dated 1/7/10 documented "Routine Labs PT/INR Frequency: BIW (twice a week) on Mon (Monday) & (and) Fri (Friday)."

The PT/INR report of 1/25/10 documented that the resident's PT was 14.3 (H/High), and the INR was 1.40 (L/low).

The physician's order dated 1/25/10 at 8:54pm documented Coumadin 4 mg (milligrams) tablet one tablet via g-tube (gastrostomy tube inserted into stomach) HS (at bedtime) discontinue, and Coumadin 5 mg tablet one tablet via g-tube HS; PT/INR on Friday AM 1/29/10.

The Medication Administration Record (MAR) documented that Coumadin 5 mg via GT HS at 10 p.m. was administered on 1/26/10 thru 2/1/10.

The PT/INR Report dated 1/29/10 documented that the PT was 23.7 (VH/Very High) and the INR was 3.30 (High).

The physician's untimed note dated 1/29/10 documented "Patient is a case of atrial fibrillation, on Coumadin increased from 4 mg to 5 mg, will follow PT/INR, no neurological deficits..."

A review of the lab results on 2/1/10 documented that the PT was very high at 35.0 and the INR was very high at 6.39. The lab result further documented that the specimen was collected on 2/1/10 at 6:00 AM and the report generated on 2/1/10 at 5:14 PM (11 hours later).

The physician's order dated 2/1/10 at 7:42 p.m. documented to Discontinue Coumadin 5 mg tablet one tablet via g-tube HS and give Coumadin 5 mg tablet one tablet via GT HS hold on 2/1/10, and 2/2/10.

The MAR for 2/1/10 documented Coumadin 5 mg via GT HS was given at 10 p.m. The MAR also documented Coumadin as "Hold" on 2/2/10, and 2/3/10.

There was no documented evidence for a physician's order to "hold" Coumadin on 2/3/10.

The PT/INR report dated 2/3/10 documented that the PT was very high at 43.9 and the INR was very high at 9.34.

The nurse's note dated 2/3/10 at 2:45 p.m. documented that the resident's PT was 43.9, and INR was 9.34. This note documented that the physician was made aware, and ordered the resident to be transferred to the hospital emergency room to rule out Coumadin Toxicity.

The nursing note dated 2/9/10 at 1:15pm documented that the resident was readmitted with a diagnosis of Coumadin toxicity.

On 3/2/10, the resident was re-admitted to the facility with diagnoses of mental status changes, and sepsis. The resident was sent out to the hospital on 2/24/10 related to behavior issue, agitation and confusion.

The physician's order dated 3/2/10 at 10:23 p.m. documented Coumadin 3 mg via G-tube at HS.

The MAR dated 3/2/10 at 10:00 p.m. documented Coumadin was not administered.

On 2/23/10, at 3:10 p.m., the Medical Director (MD #1) was interviewed and stated that he is the resident's primary doctor at the facility. He stated that he comes to the facility twice a week and would hold the Coumadin and repeat the PT/INR whenever it is necessary. The Medical Director stated that he relies on the nurse's to report labs to me. When reminded that there are a couple of missing lab reports he stated that he doesn't know why the labs were not done. The MD stated that there is no system for monitoring if the labs ordered are being done."

On 3/1/10, the day LPN #8, who worked on 1/30/10, was interviewed and stated that she did see the D/C on the MAR, and that she does not always look at the MD orders.

On 3/1/10, at 5:00 p.m., LPN #10 was interviewed and stated that they did not understand the way the MD orders were written. "It's confusing."

On 3/1/10, the Director of Nursing (DNS/RN#1) was interviewed and when asked to identify the signature of the staff who administered the Coumadin on 2/1/10, the DNS stated, "I do not know whose signature this is."

On 3/3/10 at 9:15 a.m., the night RN #7 was interviewed and she stated that she did not give the 10:00 p.m. Coumadin as ordered on 3/2/10. "It was up to the evening shift to give it when they picked up the orders. I did not notify the doctor nor did I notify the night supervisor, I should have."

The evening RN supervisor #4 was interviewed on 3/3/10 at 5:00 p.m. and she stated that after confirming the orders with the physician over the phone at around 9:30 p.m. close to 10:00 p.m., I handed the "Orders" to the LPN for her to pick up and I did not give her any special instructions about the Coumadin order. "I should have."

On 3/3/10, the DNS/RN #1 was interviewed and stated that she did not know that the resident had returned from the hospital. She stated that Coumadin 3 mg was in the resident's blister pak and should have been given. She stated that she made the physician aware and a Stat (immediately) order to administer Coumadin on 3/3/10 at 10:00 a.m. was done. The PT/INR on this resident was drawn on 3/3/10 as previously ordered.

3) Resident #53 is a 66 year old female with diagnoses which include Chronic Obstructive Asthma, Hypertension, and Osteoporosis.

The Minimum Data Set (MDS) 2.0 Assessment dated 12/18/2009 documented that the resident's cognition is Independent.

The physician's order dated 8/19/09 documented "Coumadin (a blood thinning drug/prevents formation of blood clots) 2.5 mg. (milligrams) tablet one tablet by mouth 1 time a day. Dx (diagnosis) Atrial Fibrillation."

The physician's orders dated 9/15/09, 11/10/09, 12/15/09 documented weekly PT/INR (Prothrombin/International Normalized Ratio, blood clotting indicators).

There was no documented evidence that PT/INR was done weekly as ordered on 9/23/09, 11/23/09, and 12/23/09.

On 12/25/09, at 10:30 p.m., the interdisciplinary progress note documented the resident is alert and verbally responsive. No acute distress was observed with episode of nose bleed for about 20 minutes on and off from the resident's (R) right nostril.

On 12/25/09, at 11:45 p.m., the nursing progress note documented that the resident was noted with "...nose bleed, pressure applied, + (plus)... pack for 15 minutes. Resident's nose continued to bleed. M.D. (Medical Doctor) notified. Verbal order given to transfer resident to hospital for further evaluation. Vital signs: 116/64 (Blood Pressure), 86 (Pulse), 22 (Respiration), 97.9 (Temperature)."

On 12/26/09, the nursing progress note documented resident left the unit at 12:25 a.m. in no acute distress with continued bleeding.

On 12/30/09, the MD #3 (facility) note documented that the resident was hospitalized for persistent nasal bleeding.

The Patient Review Instrument (PRI) dated 12/31/09 documented that the resident's primary diagnosis was Epistaxis Coagulapathy due to Coumadin Toxicity.

The medical record documented the resident was readmitted to the nursing home on 1/2/10.

On 2/25/10 at 8:50 a.m., during interview with the MD #3, the physician stated "The resident's INR has been high. The reason could be the Prilosec. Prilosec could elevate the INR. She has been on Prilosec for almost one year."

On 2/26/10 at 4 p.m., the LPN #4 was interviewed and stated that the weekly PT/INR slip was not filled out so the blood work was not done.

4) Resident #14 a 62 year old male admitted to the facility with diagnoses which include Atrial Flutter on Coumadin, Acute Systolic Heart Failure , Status post Incarcerated Abdominal Hernia, Hypertension, status post Internal Cardiac Device Implantation.

The Minimum Data Set 2.0 Assessment dated 12/15/09 identified the resident as moderately impaired with poor decision making, needs cueing, and required supervision.

The nursing note by the Registered Nurse (RN) dated 1/6/10 documented that the resident was readmitted status post incarcerated ventral hernia, urinary tract infection, C. difficile, sacral wound stage III, and multiple ischemic left leg ulcers. The note further documented that the physician was notified and orders were obtained.

The physician's telephone order dated 1/6/10 at 10:33 p.m. documented the following:
-Combivent Inhaler (Albuterol + Ipratropium) 2 puff/inhalations by mouth 2 times a day;
-Aspirin EC (Enteric Coated) 81 mg (milligram) Tablet, 1 tablet by mouth 1 time a day;
-Ciprofloxacin 500 mg. Tablet, 1 tablet by mouth 2 times a day;
-Coumadin 3 mg Tablet 1 tablet by mouth HS (bedtime).

The physician's order further documented that the order was reviewed on 1/7/10 at 12 a.m., and 1/7/10 at 7-3 a.m., and signed as picked up on 1/8/2010 at 3-11 shift.

The Medication Administration Record (MAR) documented that Albuterol, Aspirin, Ciproflaxacin, and Coumadin were not administered as ordered on 1/6/10 to 1/8/10.

The 1/7/10 nursing note documented "...At 12N (noon) SOB (shortness of breath) noted pulse ox (oximeter) at 86% at Rm (room air). pulse 106...."

The LPN nursing note dated 1/8/10 at 10pm documented "... General weakness noted and notified RN supervisor...."

There is no documented evidence that the RN Supervisor evaluated the resident's "general weakness".

The lab report for PT/INR collected on 2/19/2010, and report generated on 2/26/10 at 3:15 p.m. documented that the resident's PT was 50, and INR was >10. This report documented "This report contains critical values."

There was no documented evidence that the physician was notified timely of the critical lab values of 2/19/10.

On 2/19/2010 at 10:00 p.m., the physician's telephone order documented discontinue Coumadin 6 mg one tablet by mouth HS for diagnosis of atrial fibrillation, and PT/INR on Monday 2/22/10. The order was picked up on 2/19/10 at 11 p.m.

Review of the MAR for 2/19/2010 documented Coumadin 6 mg 1 tablet by mouth was administered at 10:00 p.m.

On 2/20/10, untimed, nursing note by the RN documented including, "PT>50 and INR>10. The physician was informed and order to repeat PT/INR on 2/22/10. Currently receiving 6 mg Coumadin. Order given to discontinue Coumadin until blood work is done. Voiding clear amber urine. Brownish spot noted on incontinent pad. No sign of active bleeding. Staff instructed to report changes..."

There was no documented evidence that the physician was notified of the "brownish spot noted on incontinent pad."

The lab report dated 2/22/10 documented PT was >50, and INR was >10.0. This report documented that "This report contains critical values and documented that the specimen was collected on 2/22/10 at 6:05 AM, and report generated on 2/22/10 at 2:07 PM.

The nurses' note dated 2/22/10 at 2:55 p.m. documented "...at 2:30 p.m., on changes blood noted on diaper covering from penis. Supervisor made aware....v/o (verbal order) from the physician, send resident to hospital..."

The Registered Nurse note dated 2/22/10 at 2:55pm documented "Resident alert, bright red blood from penis, resident denies any pain, ... Dr. , send resident to ...hospital..."

During an interview with the LPN #4 on several occasions and various time during the survey process, she stated that the LPNs are allowed to call and take telephone orders from the MD and put this information on the computer. After putting in the information, the LPN calls the RN/RN Supervisor to release it. However, the printed MD record will show the time and the name of the RN who release it and not the original licensed nurse who spoke and took the order from the telephone order from the physician. The LPN further stated it is only the RN/RN Supervisor and 2 LPNs who are given the privilege and designated to release the telephone or verbal orders that has been input into the computer.

The RN #3 covering the 7-3 shift was interviewed on 3/8/2009 at 11:00 A.M. stated "I have been saying for a long time, that it is not right. The LPN called in the MD for telephone orders, and then I come and released it. The record will show I got the telephone order even if I was not the one."

The 3-11 shift RN Supervisor (RNS #4) was also interviewed and stated that the LPN writes and gets the telephone order and inputs into the computer. The RN who released it will be on record as the one who received the verbal or telephone call from the MD. The time may not be the same time that it was called in. The RN Supervisor further stated that she covers 3 units and ensures that when she makes her rounds, she goes and checks the orders in the computer. The computer is set that it will have a box to remind us of what is pending.

The Director of Nursing (DNS/RN #1) was interviewed on 3/8/2010 at 7:45 p.m., and stated, "the computer for MD order is directly connected to the pharmacy, and the RNs are designated to release the orders."

The Administrator was interviewed on 3/8/10 at 8:00 p.m., and stated that the facility had designated the RNs to release any MD order from the computer, and that they are to call and clarify again from the MD before releasing it.

415.12

Based on record reviews and staff interviews, the facility did not ensure that issues, including Coumadin medication regimen, and abnormal/critical laboratory reports to which quality assessment and assurance activities are necessary, were identified and that appropriate plans of action were formulated to correct the identified deficiencies cited under F309 and F505.

This resulted in actual harm to residents that is not immediate jeopardy.( #11, #52, #53, #55, and #57)

The findings are:

During the course of interviews, it became evident that multiple inconsistencies in responses were given in areas such as frequency of QA (Quality Assurance) meetings, topics of discussion during QA meetings, members who attend such meetings and delegation of responsibility.

On 3/8/10, at approximately 10:55 a.m., the Administrator was interviewed at which time he stated that QA meetings are held monthly, and attended by the medical director, director of nursing (DNS), and all department heads, as well as several randomly selected staff. The administrator deferred most of the QA related responsibilities to the DNS. When asked how information is disseminated to providers of care, he indicated that the the nursing director is responsible for the communication to providers.

On 3/8/10, at approximately 12:05 p.m., the Director of Nursing was interviewed and stated that she attends monthly QA meetings with all department heads and the medical director present. The DNS also stated that she was aware of problems related to Coumadin monitoring and Coumadin toxicity which she attributed to instability in resident condition. She did however address that there were some "kinks" in areas of monitoring where the systems addressed above were not as effective. She stated that "we have to do more inservicing."

On 3/8/10, at approximately 12:55 p.m., the Medical Director was interviewed at which time he stated that he does not attend the regular QA meeting but attends a meeting every three months which is attended by the Administrator, DNS, Social Worker, Dietician and 3 members of the Board of Directors. He indicated that admission concerns and cases are discussed at these meetings. He indicated that these are not the medical board meetings. He made reference to several meeting types but could not elaborate on recent discussions at the quality assurance meetings, its frequency or give responses consistent with the DNS or Administrator. The medical director did identify that he was aware of a PT/INR issue in the facility that could be addressed through an increase in lab work frequency, but made no mention of it as a topic for quality assurance. He was asked if he was aware of any statistics on recurrent hospitalizations for different conditions and his response was that he was unaware, but confident that the Administrator, DNS and Finance department had them.

On 3/8/10, at approximately 6:20 p.m., the QA Coordinator was interviewed. During the interview she indicated that she did not know when the last QA meeting was held or what the regular QA schedule was. She stated that the meeting is typically attended by the Administrator, DNS, Director of Social Services, all department heads and the Chief Financial Officer. She stated that the Administrator sets the QA schedule. When asked if she was aware of any hospitalization trend developments in the past year or any related statistics, she stated that she could not remember. She stated that the DNS handles that area.

415.27(a-c)

Based on record review and staff interviews, the facility did not ensure that a resident is free of significant medication errors as evidenced by administering medications that was discontinued by the physician resulting in Coumadin toxicity and hospitalization. This was evident for one (1) of 24 sampled residents. (Resident #11)

This resulted in actual harm that is not immediate jeopardy.

The finding is:

Resident #11 is an 87 year old male re-admitted on 2/9/10 with diagnoses that included Coumadin Toxicity, Atrial Fibrillation, Hypertension, and Congestive Heart Failure.

The Minimum Data Set (MDS) 2.0 Assessment dated 1/8/10 documented that the resident is moderately impaired for cognitive skills for daily decision making, and requires total care for activities of daily living.

The physician's order of 1/25/10, 3-11 shift, documented "Coumadin (a blood thinning drug/prevent formation of blood clots) 4 mg (milligrams) tablet one tablet via g-tube (GT, gastrostomy tube, tube inserted into stomach for feeding) HS (at bedtime) discontinue, and Coumadin 5 mg tablet one tablet via GT HS; PT/INR (Prothrombin/International Normalized Ratio, blood clotting indicators) on Friday AM 1/29/10 Dx (Diagnosis) Atrial Fibrillation."

The nurse's note dated 1/27/10 at 3:00 p.m. documented that the resident had loose BM (bowel movement) 4 times on this shift. To start Flagyl 500 mg. via GT BID (twice a day) for 5 days. Stool for Clostridium difficile result pending.

The physician's order dated 1/27/10 documented: Flagyl 500 mg (milligrams) tablet (Metronidazole) one tablet via g-tube 2 times a day. Days: 5 Diagnosis: Loose Bowel Movement.

Review of the MAR (Medication Administration Record) documented: Flagyl 500 mg 1 tab via G-tube BID was given on 1/27/10 at 10 p.m.; on 1/28/10 at 10 a.m. and 10 p.m.; and 1/29/10 at 10 a.m. (4 doses).

On 1/28/10, the microbiology report for Clostridium (C.) difficile documented a "Negative" result.

The physician's order dated 1/29/10 at 3 p.m. documented to discontinue Flagyl 500 mg Tablet (Metronidazole) one tablet via g-tube 2 times a day

The physician's note of 1/29/10, untimed, documented: "Patient is a case of atrial fibrillation, on Coumadin increased from 4 mg to 5 mg, will follow PT/INR, no neurological deficits. The resident's C. difficile toxin negative, antibiotic discontinued."

The MAR further documented that the resident continued to receive the Flagyl for 5 more doses after it was discontinued by the physician. The resident received Flagyl on 1/30/10 at 10 a.m. and 10 p.m.; on 1/31/10 at 10 a.m. and 10 p.m.; and on 2/1/10 at 10 a.m.

The PT/INR Report dated 1/29/10 documented: PT=23.7 (VH/Very High)/INR=3.30 (H).

A review of the lab results on 2/1/10 documented PT=(VH) 35.0 / INR=(VH) 6.39. Date Collected: 2/1/10 at 6:00 AM and generated on 2/1/10 at 5:14 PM. (11 hours later)

The physician's order dated 2/1/10 at 7:42 p.m. documented: "Discontinue Coumadin 5 mg tablet one tablet via g-tube HS;...Coumadin 5 mg tablet one tablet via GT HS hold on 2/1/10, and 2/2/10."

The MAR dated 2/1/10 documented: Coumadin 5 mg via GT HS was signed as given at 10 p.m., two hours after the physician ordered to discontinue the Coumadin.

The resident at this time was on Coumadin and Flagyl. Coadministration of Coumadin with Flagyl may increase the effect of Coumadin. The potential interactions could be associated with bleeding and increased PT/INR blood levels. The patients should be closely monitored during concomitant therapy.

The PT/INR report dated 2/3/10 documented: "...PT=(VH) 43.9,/(VH) INR= 9.34..." This report was signed by the physician on 2/4/10.

The nurse's note dated 2/3/10 at 2:45 p.m. documented the resident's PT=43.9, and INR=9.34. The physician was made aware, and ordered the resident to be transferred to the hospital emergency room for rule out Coumadin Toxicity.

On 2/9/10, the resident was readmitted with diagnosis of Coumadin toxicity.

On 2/23/10, at 3:10 p.m., the Medical Director (MD #1) was interviewed and stated that he is the resident's primary doctor at the facility. He stated that he comes to the facility twice a week and stated, "I was aware that the Flagyl interacts with Coumadin that is why I was monitoring the PT/INR two times a week and when necessary. I usually would hold the Coumadin and repeat the PT/INR. My target for atrial fibrillation INR is 3.0. A little higher is okay. INR of 3.5 is not bad. I rely on the nurse's to report labs to me. .... I did not know that my patient was still getting the Flagyl and Coumadin after they were discontinued. This can definitely be a cause for an elevated INR."

On 3/1/10 at 1:00 p.m., the 7-3 p.m. shift LPN #12, who worked on 1/29/10, was interviewed and stated that she picked up the order to discontinue Flagyl. She stated, "I D/C (Discontinued) it on the MAR but did not draw a line across it. I just wrote the letters D/C at the end date it was suppose to be completed."

On 3/1/10, the day LPN #8, who worked on 1/30/10, was interviewed and stated that she did see the D/C on the MAR, and that she does not always look at the MD orders.

On 3/1/10, at 4:00 p.m., the evening LPN #7, on duty on 1/30/10, was interviewed and stated that she was not sure when shown the Physician's Order for Flagyl that the order itself was discontinued. "It's pretty confusing this order." The LPN stated that she did not look back to the initial MD orders and that she did not see the "D/C" on the MAR.

On 3/1/10, at 5:00 p.m., LPN #10 was interviewed and stated that the way the MD orders were written is confusing.

On 3/1/10, the Director of Nursing (DNS/RN #1) was interviewed and when asked to identify the signature of the staff who administered the Coumadin on 2/1/10 while on "Hold Orders," the DNS stated, "I do not know whose signature this is. The DNS stated that she was not aware the staff were giving Flagyl and Coumadin when it was ordered to be held.

During an interview with the LPN #4 on several occasions and various time during the survey process, she stated that the LPNs are allowed to call and take telephone orders from the MD and put this information on the computer. After putting in the information, the LPN calls the RN/RN Supervisor to release it. However, the printed MD record will show the time and the name of the RN who release it and not the original licensed nurse who spoke and took the order from the telephone order from the physician. The LPN further stated it is only the RN/RN Supervisor and 2 LPNs who are given the privilege and designated to release the telephone or verbal orders that has been input into the computer.

The RN #3 covering the 7-3 shift was interviewed on 3/8/2009 at 11:00 A.M. stated "I have been saying for a long time, that it is not right. The LPN called in the MD for telephone orders, and then I come and released it. The record will show I got the telephone order even if I was not the one."

The 3-11 shift RN Supervisor (RNS #4) was also interviewed and stated that the LPN writes and gets the telephone order and inputs into the computer. The RN who released it will be on record as the one who received the verbal or telephone call from the MD. The time may not be the same time that it was called in. The RN Supervisor further sated that she covers 3 units and ensures that when she makes her rounds, she goes and checks the orders in the computer. The computer is set that it will have a box to remind us of what is pending.

415.12(l)(1)

Based on observations and staff interviews, the facility did not ensure that maintenance and housekeeping services were provided to ensure that the resident's environment was sanitary and comfortable as evidenced by: stained missing or broken ceiling tiles, chipped off and peeling wall paints, dirty and broken furniture, missing and broken baseboard, cracked floor tiles and dirty windows. This was evident for 4 of 4 floors (1st, 2nd, 3rd and 4th floor).ne
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 2/22/10 and 2/23/10 between 9:00a.m. and 5:00 p.m., the following was observed:

1) Stained and/or wet ceiling tiles were noted throughout the facility in locations and that include but not limited to the, soiled and clean utility rooms on the 4th and floor, 3rd floor stairwell landing, 3rd and 2nd floor soiled utility rooms and inside both tub rooms on the 3rd and 4th floors.

In an interview with the Director of Environmental services at approximately 2:30 p.m. on 2/23/10, he stated that most of the stained/wet ceiling tiles noted are as a result of condensation. However the stained ceiling tiles noted on the 4th floor are as a result of the roof repair that is being done as part of the Architectural Engineering project # 3856. He further stated that the ceiling tiles on the 4th floor were not promptly replaced because he knew that through the fixing of the roof there will be a lot more stains, therefore he was waiting until the roof repairs was done to change the tiles. He also stated that the ceiling tiles on the other floors would be changed as soon as possible.

2) Chipped off and peeling wall paint was noted inside the main dietary storage room and along the corridor leading to the dietary storage. In an interview with the Director of maintenance at approximately 2:45 p.m. on 2/23/10, he stated that painting is usually done as per needed and therefore as these spots were pointed out they will be repainted immediately, he further stated that these areas must have been an oversight during weekly rounds.

3) The main lounge located on the 1st floor of the facility was equipped with 2 sofas and a love seat. They were heavily soiled with blackish grease and grime at the top and on the handles. There was also 1 ripped chair observed in room 304. On 2/23/10 at approximately 11:30 a.m. while conducting inspection on the second floor the piano inside the day/dining room was observed covered with a thick layer of dust.

In an interview with the Director of Environmental Services at approximately 1:00 p.m. on 2/23/10 he stated that he has a furniture log book and he does rounds once per month however, he did not notice any chairs being ripped and the dirty condition of the lounge sofas and piano.

4) On 2/22/10 at approximately 11:40 a.m., missing and broken baseboard was noted along corridor walls at the entrance of the main dietary storage and around the periphery to the entire dietary storage room.

5) On 2/23/10 at approximately 10:30 a.m. cracked floor tiles were noted in the West Side tub room on the 3rd floor and on the same day at approximately 1:00 p.m. a missing drain cover was observed in the corridor on the first floor in front of the beauty parlor and across from the resident public telephone.

When interviewed on 2/23/10 at approximately 3:30 p.m. the Director of environmental services stated that all the issues should have be found during weekly rounds and corrected, but somehow were overlooked. He further stated that the issues will be taken care of immediately and more stringent measures would be taken while doing rounds and delegating and validating responsibilities.

6) During the inspection on 2/22/10, between the hours of 9:00 a.m. and 4:00 p.m., water drip marks and water condensation build-up were observed on at least 10 resident room windows and day/dining room windows on floors 3 through 5. As a result, it was not possible to see clearly through the windows. Examples include but are not limited to the following:
3rd floor: Rooms 322, 306, 307, 315 and the day/dining room.
4th floor: Rooms 406, 408, 410,and 412.

The Director of Environmental Services was interviewed on 2/22/10 at 12:50 p.m. and he stated that "we do not have a maintenance contract for washing the exterior of the windows and that he could not recall when they were last done".

The Administrator was interviewed at approximately 1:30pm on 2/22/10 and he stated that "we typically do the windows ourselves every spring and that they could probably benefit from a cleaning." he then stated that he would schedule a cleaning of the exterior of the windows throughout the facility.

415.5(h)(2)

Based on observations, record reviews and staff interviews, the facility did not ensure that the physicians' orders were implemented in accordance with each resident's written plan of care as evidenced by:

1) The PT/INR (Prothrombin/International Normalized Ratio, blood clotting factors) were not done. (Residents #11, #52, and #57);

2) The physician's order to administer and/ or discontinue medications were not followed. (Resident #11);

3) The Dilantin level was not done. (Resident #12);

4) The resident's brace on right arm/elbow was not applied and removed every 2 hours as ordered. (Resident #51); and

5) The Occult Blood (a test to monitor gastrointestinal bleeding) was not done. (Resident #57)

This was evident for 2 of 24 sampled residents and 3 expanded sampled residents. (Residents #11, #12, #51, #52, and #57)

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

The findings are:

1) Resident # 57 is an 81 year old female with diagnoses which include Deep Vein Thrombosis, Intracranial Hemorrhage, Cerebrovascular Accident, Hypertension, and Migraine. She was admitted to the facility on 6/12/08 with medications including Coumadin and Prilosec.

The Minimum Data Set 2.0 Assessment dated 10/10/09 documented that the resident's cognition is modified independent with short term memory problems. She is incontinent of bowel and bladder.

The physician's order dated 8/4/09 documented "Flagyl 500 mg for 5 days Q (every) 8 Hrs (hours), V/S (vital signs) Q shift, Stool for occult blood & (and) C (Clostridium) Difficile (a bacterial infection that causes diarrhea)."

The lab for Stool for C-difficile was collected on 8/14/09 and reported on 8/17/09 "Positive for Toxin A and/or B." There was a 10 day delay in the collection of the stool specimen.

The physician's order dated 8/11/09 documented that the Coumadin was decreased from 2.5 mg (milligrams) tablet to 2 mg tablet at bedtime.

The physician's order dated 8/14/09 documented "... PT/INR frequency weekly..."

There was no documented evidence that the physician's order was followed for weekly PT/INR to be drawn on 8/17/09, 8/31/09, and 9/7/09.

The physician's order dated 9/11/09 documented PT/INR ordered weekly.

There is no documented evidenced that the PT/INR weekly labs were done on 9/21/09 and 9/28/09.

On 3/2/10, at 2:35 p.m., the Director of Nursing (DNS/RN #1) was interviewed and stated that when labs are ordered, there should be a specific day of the week included. The lab tech routinely comes to the facility on Monday, Wednesday and Friday. The Licensed Practical Nurse (LPN) picks up the physician order, some nurses fill out a requisition sheet for 2-3 months in advance and some may not. When asked who is responsible for ensuring that the labs are done, she stated that there is no process in place to ensure that labs ordered were done.

On 3/2/10 at 3:30 p.m., the LPN #5 was interviewed and stated that he picks up the physician's order, fills out a lab sheet, and gives directions to the CNA (Certified Nursing Assistant) to collect the stool.

On 3/3/10 at 11:52 a.m., the Medical Director (who was covering for MD #1) was interviewed and stated that when there is an order he expects that it will be done. He stated that his method for following up on his orders is that he relies on the nurses to call him and he normally remembers.

On 3/3/09, at 5:50 p.m., the 3-11 LPN #6, who picked up the Physician's order on 9/11/09, was interviewed. She stated that when she picks up a lab order she fills out a lab sheet and puts it in the lab book. She only fills out the first date for the PT/INR if the order is weekly. She added that there should be a list behind the nurse station with all the residents who are on weekly labs. When asked who checks the paper at the Nurse station she stated the night Nurse. When asked who follows up on a lab to ensure it is done, she did not respond.

On 3/5/10 at 11:45 a.m., the Lab Technician #1 was interviewed and stated that when she goes to the unit the lab sheets are in the lab book ready for her. She stated that she does not know anything about the resident's medical condition or medications that she just takes the lab sheet, goes to the resident and draws the blood. Lastly, she does not know who is on weekly labs.

2) Resident #52 a 94 year old female admitted to the facility with diagnoses which include: Alzheimer's, Hypertension, Hyperparathyroidism, Osteoarthritis, Anemia, Deep Vein Thrombosis, and on Coumadin therapy.

The Minimum Data Set 2.0 Assessment dated 10/30/09 identified the resident as severely impaired with cognition, and needs total care with all Activities of Daily Living.

The physician interim order dated 9/3/09 documented an order to repeat PT/INR on Monday 9/7/09. This order further documented Coumadin 4 mg at bedtime.

There is no documented evidence that the PT/INR was done on 9/7/09.

The physician orders dated 9/11/09 documented PT/INR every Wednesday and Coumadin 5 mg at bedtime.

There is no documented evidence that the PT/INR was completed on 9/18/09 and 9/25/09.

The physician order dated 10/30/09 document repeat PT/INR on Monday, 11/2/09.

On 11/2/2009, there was no documented evidence that PT and INR were done as ordered by the physician.

The LPN #2 on the third floor unit was interviewed and stated the monthly orders are carried out by the 7-3 shift, but if a resident has a weekly blood test, the 11-7 LPN fills out the form. She illustrated it by saying, a resident with order of PT/INR weekly, the name is written on a list that is posted in the nursing station. The 11-7 LPN makes the slip the night before it is due. The laboratory technician comes in the morning and takes all the resident due for that date.

On 2/26/2010, the Laboratory Supervisor was interviewed by phone on with the LPN and stated, he did not have any record of blood test for PT/INR for dates 9/18/2009, and 9/23/2009.

3) Resident #11 is an 87 year old male re-admitted on 2/9/10 with a diagnosis that included Coumadin Toxicity, Atrial Fibrillation, Hypertension, and Congestive Heart Failure. On 3/2/10 the resident was re-admitted with a diagnoses that included Mental Status Changes and Sepsis.

The Minimum Data Set (MDS) 2.0 Assessment dated 1/8/10 documented that the resident is moderately impaired for cognitive skills for daily decision making, and requires total care for activities of daily living.

Review of the physician's orders dated 7/29/09, and 8/24/09 documented, Coumadin 3 mg (milligrams) tablet one tablet via G-tube (gastrostomy tube, tube inserted into stomach) at bedtime. The physician's orders further documented: "Routine Labs PT/INR (Prothrombin Time/International Normalized Ratio) Frequency: BIW (twice a week) on Mon (Mondays) and Fri (Fridays).

The laboratory report dated 9/4/09 documented: PT=12.1, and INR=1.06 The report had a physician notation, "9/5/09 increase Coumadin to 4 mg HS via G-tube. Recheck PT/INR on Monday (9/7/09)."

There was no documented evidence that the PT/INR blood levels were checked on 9/7/09 (Monday), and 9/11/09 (Friday) as ordered.

A review of the physician's order dated 1/7/10 documented for PT/INR BID (twice a week) on Monday and Friday.

The nurse's note dated 1/27/10 at 3:00 p.m. documented the resident had loose BM 4 times on this shift. To start Flagyl 500 mg. via GT BID (twice a day) for 5 days. Stool for Clostridium difficile result pending.

On 1/28/10, the microbiology report for C. difficile (Clostridium difficile, a bacterial infection that causes health care associated diarrhea) documented a "Negative" result.

The physician's order dated 1/29/10 at 3 p.m. documented to discontinue Flagyl 500 mg Tablet (Metronidazole) one tablet via g-tube 2 times a day.

The Medication Administration Record documented that the resident received the Flagyl for 5 more doses after it was discontinued by the physician (from 1/30/10 at 10 a.m. and 10 p.m.; on 1/31/10 at 10 a.m. and 10 p.m.; and on 2/1/10 at 10 a.m.).

The physician's order dated 2/1/10 at 7:42 p.m. documented: Discontinue Coumadin 5 mg tablet one tablet via g-tube HS;...Coumadin 5 mg tablet one tablet via GT HS hold on 2/1/10, and 2/2/10.

Review of the MAR for 2/1/10 documented: Coumadin 5 mg via GT HS was given at 10 p.m. (1 dose) after the physician ordered to discontinue the Coumadin.

On 3/1/10 at 1:00 p.m., the 7-3 p.m. shift LPN #12, who worked on 1/29/10, was interviewed and stated that she picked up the order to discontinue Flagyl. She stated, "I D/C (Discontinued) it on the MAR but did not draw a line across it. I just wrote the letters D/C at the end date it was suppose to be completed."

On 3/1/10, the day LPN #8, who worked on 1/30/10, was interviewed and stated that she did see the D/C on the MAR, and that she does not always look at the MD orders.

On 3/1/10, at 4:00 p.m., the evening LPN #7, on duty on 1/30/10, was interviewed and stated "It's pretty confusing this order." The LPN stated that she did not look back to the initial MD orders and that she did not see the "D/C" on the MAR.

On 3/1/10, at 5:00 p.m., two LPNs #7, and LPN#10 were interviewed and stated that they did not understand the way the MD orders were written. "It's confusing."

On 3/1/10, the Director of Nursing (DNS/RN #1) was interviewed and when asked to identify the staff who administered the Coumadin on 2/1/10 the DNS stated, "I do not know whose signature this is." The DNS stated that she was not aware the staff were giving Flagyl and Coumadin when it was ordered to be held. The DNS also stated that the all residents on Coumadin are noted in the 24 Hour Nurse Report.

A review of the physician's order dated 3/2/10 at 10:23 p.m. documented for Coumadin 3 mg via G-tube.

A review of the MAR dated 3/2/10 at 10:00 p.m. documented that Coumadin was not signed off as "given."

On 3/3/10 at 9:15 a.m., the RN #7 was interviewed and she stated that she did not give the 10:00 p.m. Coumadin as ordered on 3/2/10. "It was up to the evening shift to give it when they picked up the orders. I did not notify the doctor nor did I notify the night supervisor, I should have."

The evening RN supervisor (RNS #4) was interviewed on 3/3/10 at 5:00 p.m. and she stated that after confirming the orders with the physician over the phone at around 9:30 p.m. close to 10:00 p.m., I handed the "orders" to the LPN for her to pick up and I did not give her any special instructions about the Coumadin order. "I should have."

On 3/3/10, the Director of Nursing (DNS/RN #1) was interviewed and stated that she did not know that the resident had returned from the hospital. She stated that Coumadin 3 mg was in the resident's blister pak and should have been given. She stated that she made the physician aware and a Stat (immediately) order to administer Coumadin on 3/3/10 at 10:00 a.m. was done. The PT/INR on this resident was drawn on 3/3/10 as previously ordered.

4) Resident #12 a 51 year old female admitted to the facility with diagnoses which include Hypotension, Anemia, Dementia, Legally Blind, End Stage Renal Disease on Hemodialysis, and with history of Seizure Disorder.

The Minimum Data Set (MDS) 2.0 Assessment dated 12/16/2010 documented the resident is severely impaired with her cognition, and totally dependent on staff for all Activities of Daily Living.

The physician's order dated 1/29/2010 documented:
1. Dilantin 100 mg/cap (milligram per capsule) 4 caps stat (immediately)
2. Dilantin 300 mg after 4 hours
3. Dilantin 300 mg after 4 hours
4. Resume regular dose in AM, and Dilantin level on 2/1/2010.

There was no documented evidence that the Dilantin level was done on 2/1/2010.

The LPN #4 in charge of the unit was interviewed on 2/24/2010 at 12:00 p.m., and stated she will look for it, and will get back. She stated the result was available, but was written with the wrong resident's name and it was in the Director of Nursing office for Quality Assurance. When asked if the physician had been informed, she stated she is not aware but will call the DNS.

The DNS/RN#1 was interviewed on 2/24/2010 at 12:10 p.m., and stated when the result came, it was written with the wrong name but right room number. She stated she instructed the Registered Nurse Supervisor on duty to inform the physician and reorder the blood test.

There is no documented evidence that the physician was notified.

5) Resident #51 a 70 year old male admitted to the facility with diagnoses which include Atrial Fibrillation with Coumadin, Hypertension, Schizophrenia Disorder, and a Permanent Pacemaker.

Thr Minimum Data Set (MDS) 2.0 Assessment dated 12/22/2009 identified the resident's cognition as moderately impaired, and dependent on staff for Activities of Daily Living.

The physician's order dated 2/25/2010 documented: brace on right arm/elbow, 2 hours on and 2 hours off.

On 3/2/2010, from 9:35 a.m. to 12:00 p.m., and on 3/3/2010 from 9:45a.m. to 12:00 p.m., the resident was observed in the Dining Room/Activity Room (DR/AR) . He was observed with a brace on his right arm extending to the elbow. During both observations staff did not remove the resident's brace as ordered by the physician.

Review of the Certified Nursing Assistant Accountability Record (CNAAR) from 1/1/2010 to 3/8/2010 documented that the resident's brace had to be released every 2 hours. There was no documented evidence of the application time and the released time of the brace on the CNAAR.

During an interview with the CNA #7 on 3/3/2010 at 12:05 p.m., she stated that she had not removed the resident's right arm brace.

415.11(c)(3)(ii)

Based on observation, and staff interview, it was determined that the facility did not store, prepare, distribute and serve food under sanitary conditions to prevent food borne illnesses. Reference is made to the following: 1) undated, unlabeled, uncovered and expired food items, 2) inappropriate storage of raw food with ready to eat food, 3) bulk delivery of food items stored directly on floor, 4) dirty equipment stored next to clean equipment and within food prep area, 5) Missing griddle knobs, broken and dirty stove and dishwashing equipment.

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

The findings are:

During the kitchen inspection on 2/22/10 and 2/23/10 the following were observed in the walk in freezer:

(1) On 2/22/10 at approximately 9:20 am, 2 cases of patties stored in a yellow plastic wrapping were undated and one 1 large packet of what appeared to be 12 fish was unlabelled.
In the reach in refrigerator 2 sets of 12 things that appeared to be pita bread were unlabelled and stored with an expiration date of 2/10/08.
Dry food such as cornmeal, peas and curry powder with partially torn original wrappers were stored inside a bucket with no cover. They were not completely protected from contamination.
A large uncovered plastic container was noted on the top shelf inside the storage room containing 3 half used plastic bags of macaroni, and upon careful inspection it was observed that there were numerous adult weevils crawling around and inside the bags.

In an interview with the Food Service Director on the same day at approximately 11:45 am. he stated that all the food items identified would be disposed of immediately. He also stated that the storage room staff was in the process of conducting their weekly inventory to remove all old food and items that might have broken seals or those that have lost their labels due to stocking and re-stocking. Furthermore he stated that macaroni was used for a pasta meal the previous Monday (2/15/10) and that there were no weevils found in or outside the bags at the time.

(2) On 2/22/10 at approximately 9:45 am. inappropriate storage of raw food with ready to eat food was observed in the reach in freezer number 1. Numerous frozen items, sliced bread etc. were stored on the top shelf with a small portion of salmon and a box of smoked turkey sausages stored directly on the top of bread.
3) On the same day at approximately 9:50 am and 11:10 am bulk and boxed food items that had just been delivered were stored directly on the floor instead of on pallets. They were stored next to the walk in vegetable refrigerator and outside of the main dietary storage room.

In an interview with the Food Service Director on the same day at approximately 11:30 am. he stated that storage on the floor was not the usual practice, but that when delivery is received on Mondays they are usually put away immediately and stored appropriately but thinks that the staff were nervous because of the presence of State Department of Health surveyors.

4) On 2/23/10 at approximately 9:48 am dirty equipments were observed stored next to clean equipments within the food prep area. Examples include but are not limited to a dirty mop bucket with grayish black water next to the sandwich prep area. At the time, a dietary staff member was observed preparing peanut butter and jelly sandwiches for the daily menu alternative at the prep area. At approximately 12:30 pm. on 2/23/10 another mop bucket was noted to be stored next to the reach in refrigerator and the ice cream box inside the kitchen.

5) The dishwashing machine was noted to be equipped with two- (2) metal exhaust ducts connected to the dishwashing machine. It was observed that both exhaust duct connections were broken at the connecting point to the dishwashing machine. The point at which the equipment was broken was covered with a blackish colored substance. There was also a buildup of grime, dust and lint at the exhaust connection directly over the area where the dishes leave the dishwasher.
The ovens used in preparing meals were noted to be broken with the door handle on the bottom oven broken and had to be kept in place with duct tape. At the time of the survey, the duct tape was covered with grease and grime.
The doors to the top oven could not latch. On 2/23/10 at approximately 2:40 pm. the Food Service Director stated that the oven is used almost on a daily basis and that to ensure that correct temperatures are met during food preparation, the oven door has to be slammed hard to latch and that constant monitoring of the thermostat had to be done during cooking times. He further stated that the oven door had been that way for only about a week. The tray line temperature was noted and they met the required temperature range.
The griddle was noted to be missing all four knobs. In an interview with the food Service Director at approximately 2:50 pm. on 2/23/10 he stated that the griddle has been like that for a while and the dietary staff use pliers to turn the griddle on and off.

NYCRR 415.14(h)
Chapter 1 SSC Subpart 14-1

Based on observations, record review and staff interviews, the facility did not ensure that residents' receive services with reasonable accommodation of individual needs and preferences. Specifically, the residents' call buttons were not within arms reach on the 3rd floor, and a resident was not provided with clothing of appropriate size (too small). This was evident for one (1) of twenty four (24) sampled residents (Resident #16) and for 1 of 3 units (3rd floor).

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

The findings are:

1) On 2/22/10, during the initial tour to the 3 floor at 9:00 a.m. to 10:30 a.m., the following was observed:

In rooms 306, 307, 309, and 310 the call bells were observed on the floor and behind the head of the bed. All four residents were in bed and unable to reach for the call bell.

The Licensed Practical Nurse was interviewed immediately and stated that she did not know how the calls bells ended up on the floor. The Licensed Practical Nurse further stated that it is the responsibility of the Certified Nurse Assistant (CNA) to make sure that the call bells are in place, and within the residents' reach.

On 2/22/10 at 12:20 p.m., the assigned CNA for rooms 306 and 309 was interviewed and stated that the call bells should be next to the residents, or in their hands. She stated that she usually does her rounds first thing in the morning. She checks the call bells and usually ties the call bell to the bed rail. She further stated that she does not know what happened on this day.

2) Resident #16, a 64 year old male admitted to the facility with diagnoses: Dementia with Psychosis, Sepsis, Convulsion, Pneumonia, Hypertension, Chronic Obstructive Pulmonary Disease, and Seizure Disorder.

The Minimum Data Set 2.0 Assessment dated 10/09/2009 documented the resident with severely impaired in cognition, and totally dependent with one assist in dressing. This MDS documented that the resident's height is 76 inches (6 feet 4 inches).

On 2/24/2010 at 11:45 a.m., the resident was observed in the hallway standing in front of his room holding onto the hand rail. The waist band of the resident's pants was at his pelvis exposing his diaper. Furthermore, the sweat pants he was wearing was too short ending at his calf.

An immediate interview with the CNA was conducted and he stated "The resident is tall and has no pants that fits him, that is why I put on his socks all the way up to cover his legs. I have told the Social Worker several weeks ago." On 2/24/2010, after interview with the same CNA, the resident's dresser and closet was observed with several long sleeved shirts but no pants.

The Comprehensive Care Plan for Self Care Deficits documented on 2/24/2010 "Resident keeps pulling his pants off. Case discussed with social services department and administration staff. Resident clothing will be changed to jumpsuit."

The case worker staff, covering for the social worker, was interviewed on 2/25/2010 at 10:00 a.m., and stated she was not aware of the resident having no clothes and will follow up on it.

The resident was observed for the second time on 3/2/2010 at 10:00 a.m. in his room with sweat pants that were too short ending at the midcalf.

The CNA assigned on this day was interviewed and stated "When I came in he was wearing that sweat pants already."

The Director of Social Services was interviewed on 3/3/2010 at 4:40 p.m. and stated that every three months she makes her rounds in the units asking and checking residents who needs clothing. She further stated that she monitors the residents' clothing need but doesn't keep a record. She stated that every resident gets clothing and has an invoice/purchase slip in the chart and business office.

The most recent resident record on inventory of personal effects dated 3/28/06 documented the following items listed:
socks-------- 6
shorts--------4
undershirt----3
pajamas------2
sweat pants--2
polo shirts---2

The resident financial statement was requested for the last quarter and revealed that the resident's account had $5,051.18.

415.5(e)(1)

Based on observations, record reviews and staff interviews, the facility did not ensure that the Resident Assessment Instrument accurately reflected the resident's current status for continency, transfer/locomotion and ambulation. This was evident for one (1) of twenty four (24) sampled residents. (Resident #5)

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

The finding is:

Resident #5 is a 56 year old female with a history of Gastritis, Hyperlipidemia, Schizoaffective Disorder, Diabetes Mellitus, Hypertension and Obesity.

The Minimum Data Set (MDS) 2.0 with assessed reference date of 10/30/09 documented the resident's cognitive status as having short term memory problems, and moderately impaired decision making ability. Her transfer status was noted as 2, 2 (being of limited assistance with one person physical assist). Locomotion off unit was documented as 4, 2 (total dependence with one person physical assist). Bladder continence was listed as 2 (occasionally incontinent). Mode of locomotion was listed as c=1 and d=1 (other person wheeled and wheelchair primary mode of locomotion).

The Certified Nursing Assistant-Clinical Accountability Record (CNAAR) for October 2009 documented the resident's mobility as ambulatory with supervision and continent of bladder.

The Nursing Admission Assessment dated 10/23/09 revealed Item #12, Risk Factors Per Assessment, at risk for falls/injury, elopement documented resident as bed/chairfast. The Activities for Daily Living (ADLs) section documented the resident's walking status as "8" for the period of 10/23/09-10/30/09 representing "the adl activity did not occur during the past 7 days on any shift."

The CNA who cared for the resident following her readmission from the hospital on 10/23/09 was interviewed on 2/24/10 at 5:28 p.m. and stated that the resident has always walked on her own and always toileted herself. She did not recall any use of wheelchair or incontinence problem.

On 2/26/10, at 8:40 a.m., the attending physician was interviewed and stated that he wrote an order for out of bed in wheelchair with bilateral leg rests and one person assist on 10/23/09. He stated that justification for the order was her unsteady gait at that time.

415.11(b)

Based on observation and staff interviews, the facility did not maintain infection control procedures that provide a sanitary environment. Specifically, the nursing staff did not handle the residents' personal belongings/supply in a manner that the clean and dirty belongings/supply were separated to prevent the spread of infection. This was evident for one (1) of three (3) nursing units. (Unit #3).

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

The findings are:

On 2/22/10, between 9 a.m.-10 a.m., during the initial tour of the 3rd floor the following was observed:

1) In room 308, the resident's dirty, worn shoes were sitting on the seat of the wheelchair.

2) In room 309, two bedpans were observed on the bathroom floor.

The Licensed Practical Nurse was interviewed immediately and stated that the night shift must have placed that shoes on the wheel chair. She further stated that the bedpans should not be on the floor.

On 2/22/10 at 12:40 p.m., the (11-7 a.m.) Certified Nursing Assistant was interviewed and stated that the resident's shoes should be in the closet.

415.19(a)(1-3)

Based on observations, and staff interviews, the facility did not ensure that the residents' environment remain free from accident hazards. Specifically, during the initial tour of the fourth (4th) floor Unit, the bathroom sink was observed hanging loosely on the bathroom wall. This was evident for one (1) of three (3) nursing care units. (4th Floor Unit)

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

The finding is:

On 2/22/10, at 10:00 a.m., an initial tour of the 4th floor was conducted. The bathroom sink, located on the "High Side" of the Unit, was observed with standing water. The water was clear and not draining. The sink was on a forward tilt. The screws located at the back of the sink were loosely secured against the wall. The surveyor was able to lift the front bottom part of the sink, and observed that this action allowed the pool of water to drain.

The Maintenance Log Book on the 4th floor Unit was reviewed and blank sheets of paper were noted in the log. There was no documentation noted concerning the loose sink in the bathroom.

The Licensed Practical Nurse (LPN) for the 4th floor Unit touring with the surveyor on 2/22/10, was immediately interviewed and she stated that she was not aware that there was a problem with the sink. She stated the sink was an accident hazard, and she would call for someone to repair the sink right away. The LPN instructed her staff not to use the bathroom until the sink was fixed. A sign was placed outside the bathroom door stating, "Out Of Order." Engineering was made aware.

On 2/22/10, at 12:30 noon, the sink was observed for a second time and was found to be fixed, secured, and functional.

On 2/24/10, at 12:50 p.m., the Director of Environmental Services was interviewed and he stated that he identified that there was a problem with the sink four months ago. He stated, "the tile on the wall which holds the sink was messed up." The floors have Maintenance Log Books which are kept on all units and are used as a communication for any needed repairs, leaks, and fixtures. He was not aware that the sink was as loose as it was, and that his staff should have been reporting this issue to him as it is a safety issue.

On 3/3/10, at 10:40 a.m., the regular Housekeeper assigned to the 4th floor was interviewed and he stated that he should have reported that the sink was broken "its been like this for along time." He also stated that he should have logged it onto the Maintenance Book which is kept on the units.

415.12(h)(1)

Based on observation, record review and staff interviews, the facility did not ensure that each resident was provided with medically related social services that meet resident needs. Specifically, the social worker did not ensure that a resident was provided with clothing that fit properly. This was evident in one (1) of twenty four (24) sampled residents. (Resident #16)

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

The finding is:

Resident #16 is a 64 year old male admitted to the facility with diagnoses: Dementia with Psychosis, Sepsis, Convulsion, Pneumonia, Hypertension, Chronic Obstructive Pulmonary Disease, and Seizure Disorder.

The Minimum Data Set (MDS) dated 10/9/2009 documented the resident with severely impaired in cognition, and totally dependent with one assist in dressing. This MDS documented that the resident's height is 76 inches (6 feet 4 inches).

On 2/24/2010, at 11:55 a.m., the resident was observed in the hallway standing in front of his room holding onto the side rail with his pants at his pelvis with his diaper exposed. Further more, the sweat pants he was wearing ended at his calf and was too short.

During an immediate interview with the CNA, he stated, "Resident is tall and has no pants that fits him, that is why I put on his socks all the way up to cover his legs. I have told the social worker several weeks ago."

On 2/24/2009, after interview with the same CNA, the resident's dresser and closet was observed with several long sleeved shirts but no pants.

The annual Social Work Services follow up assessment dated 1/6/10 documented to "...Continue to anticipate and meet resident's needs. Continue to re-direct resident when it's needed. Continue to encourage family visits. Social worker continue to visit 1:1 for reassurance." There is no documented evidence that the resident had a behavior of removing his pants.

The comprehensive care plan dated 1/10 for self care defiicits documented "Annual Assessment done, proceed c (with) plan of care, no changes." There is no documented evidence that the resident had a behavior of removing his pants.

The comprehensive care plan dated 1/10 for behavior documented that the resident had physically abusive, socially inappropiate, resists ADL (activities of daily living) assistance and "deterioation in problem behavior." The outcome evaluation dated 1/10 documented "Annual assessment done will proceed with care plan. There is no documented evidence that the resident had a behavior of removing his pants.

The Certified Nursing Assitant Clinical Accountability Records dated 1/10, 2/10 and 3/10 did not document that the resident had a behavior of removing his pants and did not document instructions for dressing/hygiene.

The comprehensive care plan for Self Care Deficits documented on 2/24/2010 "Resident keeps pulling his pants off. Case discussed with social services department and administration staff. Resident clothing will be changed to jumpsuit."

The resident was observed for the second time on 3/2/2010 at 10:00 a.m. in his room with sweat pants that are again too short ending at the resident's calf. The CNA assigned on this day was interviewed and stated "When I came in, he was wearing that sweat pants already."

The Registered Nurse/Minimum Data Set Coordinator who is covering the unit was interviewed on 2/24/10 and stated that the resident has a behavior of pulling off his clothing.

The case worker staff, covering for the social worker, was interviewed on 2/25/2010 at 10:00 a.m. and stated she was not aware of the resident's needs for pants and will follow up on it.

The Director of Social Services was interviewed on 3/3/2010 at 4:40 p.m. and stated that every three months she makes her rounds in the units asking and checking residents who needs clothing. She further stated that she monitors the residents' clothing needs but doesn't keep a record. She stated that every resident gets clothing and has an invoice/purchase slip in the chart and in the business office.

The most recent resident record on inventory of personal effects dated 3/28/06 documented the following items:
socks -- 6
shorts --4
undershirt --3
pajamas -----2
sweat pants --2
polo shirts ----2

The resident's financial statement was requested for the last quarter and documented that the resident had an account containing $5,051.18.

415.5 (g)(1)(i-xv)

Based on observation, record review and staff interviews, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services in a timely manner to maintain the resident's range of motion to both lower extremities. This was evident in one (1) of twenty four (24) sampled residents. (Resident #12)

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

The finding is:

Resident #12 a 51 year old female admitted to the facility with diagnoses: Hypotension, Anemia, Dementia, legally Blind, End Stage Renal Disease on Hemodialysis, and Seizure Disorder.

The Minimum Data Set (MDS) 2.0 Assessment dated 12/16/2009 documented the resident is severely impaired with her cognition. The MDS further documented: Section G3 (A) Range of Motion, b (Arm) -2-Limitation on both sides, and (B) Voluntary Movement, b (Arm) -1-Partial loss. Further review of this section revealed that the resident has "No limitation" for Range of Motion to Neck, Hand, Leg, and Foot and "No loss" for Voluntary Movement to Neck, Hand, Leg, and Foot.

The physician's order dated 2/8/2010, documented arterial doppler of both lower extremities.

The interdisciplinary note by nursing dated 2/9/2010 at 1:00 p.m. documented, "Resident with weakness noted to both lower extremities-unable to pivot in wheelchair."

The physician's order dated 2/9/2010, documented physical therapy evaluation for a resident that has weakness in both lower extremities.

On 2/22/2010 at 2:45pm, the resident seated in the wheelchair with a lapboard.

During the review of the resident's medical record on 2/22/2010, the PT consultation and doppler study results were not available on the chart.

The PT Rehabilitation Director was interviewed on 2/23/2010 at 11:00 a.m. He brought the PT evaluation dated 2/10/2010 and stated it was in his file. He stated that, normally the PT department after doing the initial evaluation will place the form in the resident's chart.

The Physical Therapy (PT) evaluation dated 2/10/2010, was reviewed on 2/23/2010, documented that resident was seen and evaluated with the following findings: resident presented with deficit in mobility, strength, and function, she can therefore benefit from PT intervention to improve these deficits. However, treatment will not begin until the results of a doppler study is obtained. Resident will be placed on nursing rehabilitation (rehab)program for ROM exercises with the following recommendation: "OOB (out of bed) in W/C (wheel chair) AROM (active range of motion) to BUE & (and) BLE (bilateral upper extremities and lower extremities) on Nursing Rehab Program." Review of the PT consultation on 2/23/10 revealed that the consult was not signed by the physician.

After reviewing the PT evaluation dated 2/10/2010 on 2/23/2010 at 11:30am, with the PT Rehab. Director, he was asked if the resident had received the recommendation to be out of bed and for active range of motion to both upper and lower extremities? He stated yes.

The nursing rehabilitation floor ambulation record documented that the resident did not receive AAROM to BUE/BLE from 2/10/2010 to 2/15/2010. The nursing rehabilitation started on 2/16/2010. The PT Director stated he was not aware it was not done.

The Licensed Practical Nurse (LPN) in charge of the unit was interviewed on 2/23/2010 at 12:45 p.m. on the result of the doppler study which was done on 2/11/2010. She stated she called the company and the results was faxed to the facility on 2/22/2010. The LPN further stated that they do not have a tracking system in place to check to see whether the requested test were done. The LPN stated that the staff in the physical therapy department file the consultations in the residents charts.

The Rehabilitation intervention note dated 2/23/2010 documented "Result of dopler test is now in and as per report 2/22/10 it is negative. Resident will now begin restorative P.T. effective 2/24/10."

415.12(e)(2)

Based on observation, record review and staff interviews, the facility did not ensure that professional standards of quality were followed. Specifically, the licensed nursing staff did not pick up, transcribe and ensure the implementation of the physician's orders in a timely manner for Combivent Inhaler, Aspirin, Ciprofloxacin and Coumadin. This was evident for one (1) of twenty four (24) sampled residents. (Resident #14) Additionally, an LPN did not notify an RN or the physician when there was a change in the resident's condition. This was evident for two (2) of thirteen (13) sampled residents in the abbreviated survey (Residents #60 and #61).

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

The finding is:

1) Resident #14 is a 62 year old male admitted to the facility with diagnoses which include Atrial Flutter on Coumadin, Acute Systolic Heart Failure, Abdominal Hernia status post incarcerated, Hypertension, status post Internal Cardiac Device Implantation. The resident has a history of multiple admissions to the facility.

The Minimum Data Set 2.0 Assessment dated 12/15/09 identified the resident as moderately impaired with poor decision making, needs cueing, and required supervision.

The nursing note by the Registered Nurse (RN) dated 1/6/10 at 6 p.m. documented that the resident was readmitted status post incarcerated ventral hernia, urinary tract infection, Clostridium difficile, sacral wound stage III, and multiple ischemic left leg ulcers. This note further documented that the physician was notified and orders were obtained.

The physician's telephone order dated 1/6/10 at 10:33 p.m. documented the following:
-Combivent Inhaler (Albuterol + Ipratropium) 2 puff/inhalations by mouth 2 times a day;
-Aspirin EC (extra coating) 81 mg (milligram) Tablet, 1 tablet by mouth 1 time a day;
-Ciprofloxacin 500 mg. Tablet, 1 tablet by mouth 2 times a day;
-Coumadin 3 mg Tablet 1 tablet by mouth HS (bedtime).

The physician's order sheet further documented that the order was reviewed on 1/7/10 at 12 a.m., and 1/7/10 at 7-3 a.m., and signed as picked up on 1/8/2010 at 3-11 shift.

Review of the Medication Administration Record (MAR) for January 2010 documented that Albuterol (Combivent), Aspirin, Ciprofloxacin, and Coumadin ordered on 1/6/10 were not administered for 32 hours later on 1/8/10: Albuterol at 6 a.m., Aspirin at 10 a.m., Cipro at 10 a.m., and Coumadin at 10 p.m.

The medical record documented for 32 hours delay from the time the licensed nurse noted that the physician's orders were obtained, and when the orders were picked up and carried.

During an interview with the Licensed Practical Nurse (LPN #4) on several occasions and various times during the survey process, she stated that the LPNs are allowed to call and take telephone orders from the MD and put this information in the computer. After putting in the information in the computer, the LPN calls the RN/RN Supervisor to release the physician's order (to the pharmacy). She further stated it is only the RN/RN Supervisor and 2 LPNs who are given the privilege and designated to release the telephone or verbal orders that has been input into the computer.

The RN #3 covering the 7-3 shift was interviewed on 3/8/2009 at 11:00 a.m. stated, "I have been saying for a long time, that it is not right. The LPN called in the MD for telephone orders and then I come and released it. The record will show, I got the telephone order, even if I was not the one who got the order."

The 3-11 shift RN Supervisor (RN #4) was also interviewed and stated, "The LPN gets the telephone order and enters the orders in the computer. The RN is the designated staff to release the orders. Whoever RN releases it, will be the RN on record who received the verbal or telephone call from the physician. The time may not be the same when the order was called in. I am covering 3 units. I make my rounds and I make it a point to go into the computer. The computer is set that it will have a box to remind us of what is pending."

The Director of Nursing (RN #1) was interviewed on 3/8/10 at 7:45 p.m. and stated, "The computer for the physician's order is directly connected to the pharmacy, and the RNs are designated to release the orders."

The Administrator was interviewed on 3/8/10 at 8:00 p.m. and stated that the facility designated the RNs to released any physician's orders from the computer, and that the RNs are to call and clarify again from the physician before releasing the orders.

Complaint # NY00082511

2) Resident #60 was an 82 year old male admitted to the facility on 6/8/07. His diagnoses included Colon Cancer, Transient Ischemic Attack, and Hypertension. According to the Minimum Data Set 2.0 (MDS), dated on 5/14/09 the resident had short term memory problems and moderately impaired cognition.

A Comprehensive Care Plan initiated on 4/22/09 identified that the resident had decreased Activities of Daily Living (ADLs) which included decreased strength, endurance, bed mobility and transfers. Interventions included restorative Occupational Therapy 5 times a week.

An Interdisciplinary Progress Note dated 5/19/09 at 3 PM documented that the resident is alert and responsive and is out of bed in wheelchair with two assist. "Resident taken to PT (Physical Therapy) but refused to participate stating he didn't fell well. Non-specific complaint given. Resident returned to the unit. " Blood Pressure 124/72, Temperature 98.2, Pulse 78, and Respiration 18.

There is no additional documentation from 5/19/09 at 3 PM until 5/20/09 at 2PM. An Interdisciplinary Progress Note written by the RN Supervisor documented, " Called to see res (resident) who vomited app (approximately) 60 cc clear fluid and ate 20% breakfast. Resident is alert color pale, skin cool to touch R (respiration) 38 Pulse Ox 81%. MD (medical doctor) called and ordered to send resident to hospital to rule out hypoxia. Ambulance responded 3PM and resident left facility at 3:05 PM. "

The following note at 4:20 PM on the same date (5/20/09) documented that a telephone call was received from the hospital to inform the facility that the resident expired at 3:50 PM.

Review of the facility's 24 Hour Report for 5/19/09 does not reveal any notation of the resident's complaint that he did not feel well.

LPN #1 (Licensed Practical Nurse) that wrote the Interdisciplinary Progress Note on 5/19/09 at 3 PM was interviewed on 2/24/10 at 11:20 AM. She stated that she remembered the resident and seeing him in the solarium on that date (5/19/09). When she asked the resident how he was doing the resident stated to her " I don't feel well " . She asked the resident if he had any pain and he denied any pain. She continued to state that the resident always says he is not feeling good. Vital signs were checked and were within normal limits. The LPN was asked what she is required to do if a resident states he does not feel well. She stated that she would normally notify the RN Supervisor but she cannot remember if the RN Supervisor was informed or whether the resident was endorsed to the next shift.

3) Resident #61 was a 72 year old male admitted to the facility on 8/20/99. His diagnoses included Cellulitis, Chronic Ulcers, Diabetes Mellitus, Hypertension and Legal Blindness. According to the MDS dated 3/28/09 he had short and long term memory problems and moderately impaired cognition.

A Comprehensive Care Plan initiated dated 7/11/08 identified that the resident had elevated glucose beyond levels normal for the resident. Interventions included monitoring glucose levels per MD orders, administering medications as ordered and monitoring for observable signs/symptoms of hyperglycemia/hypoglycemia.

An Interim Note on the Physical Therapy (PT) Progress Note dated 6/12/09 at 11:00-11:30 AM documented that during rehab therapy the resident "was not responding to name when called. Pulse 72. Resident had tried to open his mouth, no words heard. Resident was returned to the floor by PT for proper assessment by nursing. PT notified nursing on the floor and the PT Supervisor. "

An Interdisciplinary Progress Note on 6/12/09 at 3PM written by the 7AM-3PM LPN (LPN #1) documented that the resident is awake and verbally responsive but is confused. Episode of lethargy noted but is easily aroused. " T.98, 80, 18 " .

An Interdisciplinary Progress Note on 6/12/09 on the 3PM-11PM shift written by LPN #2 documented, " awake and responsive. Ate 50% of meal. B/S 277 mgdl. Resident stable v/s 98.4, 78, 20. "

An Interdisciplinary Progress Note on 6/13/09 written by the 11PM-7AM RN Supervisor #2 documented that " LPN called her at 6:10 AM to assess resident. The resident was lying in bed with no pulse, no B/P (blood pressure), no respirations or oxygen sats (saturation). Skin was cool and he was nonresponsive. CPR (Cardiopulmonary resuscitation) was started and 911 was called. EMT arrived at 6:25 AM. Resident was still without pulse B/P, respiration, and oxygen sats, Pupils were fixed and not reacting to light. (Doctor) notified. "

An Interdisciplinary Progress Note on 6/13/09 at 8:40 AM documented that " Pt. (patient) death certificate signed after exam of body and family informed. "

The 24 Hour Patient Care Record (also known as the 24 Hour Report) for 6/12/09 documents the same information written in the Interdisciplinary Notes. There is no documentation that an RN was notified of the report from physical therapy about the resident's condition. There is no documentation that the resident complained of a headache during the 3PM- 11 PM shift.

The Supervisor Communication Book for 6/12/09 was reviewed. There is no documentation pertaining to Resident # 61 on any of the 3 shifts.

The Physical Therapist (PT) was interviewed on 2/24/10 at 10:30 AM. He stated that the resident was not himself on 6/12/09, as he is usually loud coming down to therapy. On this day he was quiet and slow to respond to questions. He asked the resident a question and it would take him a few minutes to respond and then it was in a very low voice. He reported this to his PT Supervisor and then returned the resident to the nursing unit. He could not recall which nurse he reported this to, but he would have told whichever nurse was on duty.

The Physical Therapy Supervisor was interviewed on 2/24/10 at 10:30 AM. He stated that the Physical Therapist told him about the resident. The Physical Therapy Supervisor noted that the resident was alert. He remembered that the resident was responding so there was no need to call a medical emergency, however, he thought that the resident should be assessed further. The Physical Therapist then returned the resident to the unit for further assessment.

LPN #1 was interviewed on 2/24/10 at 11:20 AM. She stated that she did not remember what happened with the resident. She was given the 24 hour report for 6/12/09 to read. She stated that she does not recall why he was on the 24 hour report but he may have been on it because he was lethargic. The LPN was asked what she is supposed to do if a resident is brought to her and told that he was not feeling well. She stated that with this particular resident she knew he was a diabetic and would have checked his finger stick and then called the RN Supervisor.

LPN #2 was interviewed on 2/26/10 at 2:25 PM. He stated that later in the evening the resident complained of a headache and he reported this to the RN Supervisor (RN Supervisor #1) and the 11PM-7AM nurse (LPN #3). He took the resident's finger stick and gave him sliding scale coverage. He re-checked the finger stick and it was okay. The LPN stated that the resident was not a chronic complainer and that he was okay before he left at the end of the shift.

RN Supervisor #1 who worked on 3PM-11PM shift on 6/12/09 was interviewed on 3/2/10 at 4:35 PM. She stated that she does not recall any issues with the resident. If there had been any changes or concerns, she stated that she would have written a note in the Supervisor Communication Book and the resident's medical record.

LPN #3 who worked 11PM -7AM shift on 6/13/09 was interviewed on 3/2/10 at 4:20 PM. He did not recall receiving any type of report from the 3PM-11PM shift that there were concerns with the resident. He saw the resident when he made his rounds and a few times during the shift when he provided care for the roommate. During the last hour of the shift, a Certified Nursing Assistant (CNA) informed him that there was a problem with the resident. He went to the resident's room and found him on the bed with no pulse and a code was called.

RN Supervisor #2 was interviewed on 2/25/10 at 7:20 AM. She stated that she does not recall any concerns with the resident prior to his expiration. She was called when he was found without a pulse.

The Attending Physician was interviewed on 2/24/10 at 2:10 PM. The medical record was given to him for review. He stated that he was not informed of any changes with this resident on 6/12/09. He was only called after his death on the morning of 6/13/09.

none The Director of Nursing (DON) was interviewed on 2/25/10 at 2:00 PM. She stated that a complaint of not feeling well by a resident should be taken seriously. The resident should be placed in bed, vitals taken and the RN Supervisor should be informed. During a subsequent interview on 2/26/10 at 2:20 PM, the DON stated that the LPN should have documented the concerns noted by the Physical Therapist and the RN Supervisor should have been notified.

The facility Policy and Procedure for Resident Assessment with an effective date of 3/2004 documented that the LPN informs the RN Supervisor when there is an acute change in a resident's status and when an accident and or incident occurs. The LPN assists in obtaining vital signs. The RN Supervisor will assess the resident, collect data and notify the attending physician.

Resident #60 and Resident #61 both had a change in their condition. In both instances, LPNs were made aware of this and did not inform an RN for further assessment and medical evaluation.

415.11 (c)(3)(i)

Based on observation and staff interview, the facility did not ensure that the most recent survey result was made readily available to residents, families, and visitors. The notice of where to locate the survey result was above eye level and one would have to ask for assistance to review/receive a copy of the survey results. This was evident for 24 of 24 sampled residents.

This resulted in no actual harm with potential for minimum harm that is not immediate jeopardy.

The finding is:

Observations conducted daily between 2/22/09-3/8/10 revealed that there was a notice posted in a glass bulletin board on the first floor next to the main elevator. The notice was placed at a height well above eye level making it very difficult to read the notice. In addition, there is no copy of the current survey posted on that bulletin board. The notice instructs the reader to go to the front desk to ask for a copy of the current survey report from the security guard. There was no notice or copy of the of the current survey report posted on the units on the 2nd, 3rd, and 4th floors.

On 3/8/10, at 9:20 p.m., the Administrator was interviewed and stated, "I do not see any problem with this according to the regulations. I do not think I am out of compliance. I respectfully disagree but, if I am not following the regulations, I am not. This is easily corrected."

415.3(1)(c)(1)(v)

Based on observation, it was determined that the facility did not ensure that the lighting systems at the emergency exit to Dumont Ave. was arranged so as to ensure the continuous lighting of all parts of the means of egress, including interior and exterior landings.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include:
On 2/22/10 at approximately 12:15 p.m. it was noted that the means of egress towards Dumont Ave, a designated Emergency exit was not equipped with continuos illumination. There were a total of three lights in the area, one on the interior and two on the exterior of the building. They all were noted to be turned off. In an interview with the Director of Environmental services at approximately 12:30 p.m. on the same day he stated that the lighting affects the clear viewing of the television set that is located in the lounge, and therefore they are kept off. He also stated that this emergency exit was formerly the main entrance to the facility and when the lights are on the ambulettes and visitors come up to these doors in an attempt to enter the building. Therefore they tend to keep the lights off. It was also noted that it was raining and the pathway via this means of egress was completely dark to the public way. When switched on the lights did not come on. The Maintenance personnel replaced the bulbs at the time of the observation.
On 2/23/10 at 8:35 a.m., 11:15 a.m. 12:50 p.m. and 5:30 p.m. the lights were noted to be off and the pathway dark and not continuously lit.
In an interview with the Director of environmental services at 1:15 p.m. on 2/22/10 he stated that his staff usually conduct rounds once weekly to check for worn out bulbs and any noted worn bulbs would be changed immediately. He further stated that he would develop an audit tool to ensure that these are checked frequently.
711.2(a)(1)