Mary Manning Walsh Nursing Home Co Inc

Based on record review and staff interview, the facility did not ensure that the admission MDS (Minimum Data Set) accurately documented the resident's skin condition. This was evident for 1 of 2 residents reviewed for pressure ulcers (Resident #614).

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

The finding is:

Resident # 614 is a 96 year old male with a diagnoses which include Cerebral Vascular Accident and Kidney Disease.

The MDS 3.0 assessments dated 8/17/11 and 8/20/11 documented that the resident's BIMS score (brief interview of mental status) was 15 out of 15, indicating the resident was cognitively intact. Section M of the MDS documented that the resident did not have a pressure ulcer.

The Nursing Notes dated 8/10/11 documented the resident's skin condition as: "stage 1 pressure ulcer , very thin/fragile skin..."

The Dietary notes dated 8/16/11 documented that the resident was admitted with a stage 1 pressure ulcer.

On 12/12/11 at 2:00pm the RN (Registered Nurse) who completed Section M (skin condition) of the MDS stated that she can not recall what happened, and it must have been overlooked.

415.11 (a)(2)

Based on observations and staff interviews, the facility did not ensure that the kitchen garbage and refuse were disposed of properly. This was observed in the kitchen and the dumpster area.

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

The finding is:

On 12/9/11 at 12 noon during the 7th floor kitchen observation, the following was observed:
- On an uncovered platform dolly, there were 10 bags of garbage, and stacks of card board boxes that were near the food preparation and pot washing area. Near this platform dolly, there was on the kitchen floor a glove and three 4 ounce cups.
- Near the stove, there was a bag of garbage on the floor.
- The garbage compactor area was observed at 12:10 PM on 12/9/11, it was observed that there were 3 bags of garbage on the floor next to the compacter. The compacter was not closed and the compactor was filled to the top with garbage bags.
On 12/9/11 at 12:05 PM the Assistant Food Service Director was interviewed and stated that the kitchen garbage goes out on an open dolly via elevator, to the first floor compacter area. He further stated that there is no closed bin or trolley available in the kitchen to transport the garbage. He further stated that he is aware that the garbage has to be transported in closed containers and he does not have a written policy for kitchen garbage disposal currently.
415.14(h)

Based on resident and staff interviews, and record review, it was determined that the facility did not complete a thorough investigation of an alleged incident of abuse in a timely manner for 1 of 2 residents reviewed for Abuse (Resident #413).
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The finding is:
Resident #413 is a 69 year old female with diagnoses which include: Heart Failure, Diabetes Mellitus, Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease.
The Minimum Data Set (MDS 3.0) dated 10/20/2011 documented that the resident is cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. It also documented that the resident had no signs and symptoms of Delirium, required total assistance of one person to assist in bathing and personal hygiene.

On 12/7/2011 at 3:29 PM, the resident was interviewed and stated that she was spoken to rudely a couple of months ago by an evening CNA (Certified Nursing Assistant), but could not recall the exact date. She reported the allegation to her brother the next day, who informed the social worker. She stated that the CNA was removed from the floor and she had not seen her since then. She did not wish to elaborate any further.
An undated form entitled "Summary Report Re: Verbal Abuse complaint that was submitted on April 5, 2011 " documented, "Based upon the information that was obtained during the investigation, it has been determined that there was no evidence to support the allegation of verbal abuse....however, the CNA was found inappropriate to the resident when she told her that her back was hurting while providing care."

An undated statement from the Registered Nurse was stamped "Received Apr (April) 12 2011."

There was no documented evidence that the investigation was completed within 5 days of the allegation.

There was no documented evidence that statements were obtained from the resident, resident's brother, and the Social Worker.

There was no documented evidence that the Social Worker followed-up on the allegation.

On 12/12/11 at 3 PM the resident's Social Worker was interviewed and stated that allegations are reported verbally and via email to the Social Work Director and to the Director of Nursing (DON). He further stated that he spoke to the resident's brother and sent an e-mail regarding the allegation.
On 12/13/11 at 11 AM, the Director of Social Work was interviewed and stated that the Social Worker never gives a formal written statement in an abuse allegation occurrence report, because no written process exists. She also stated that all reports are made verbally to her and to the Director of Nursing. She stated that all e-mails regarding abuse incidents were reviewed at the quality management meeting.

On 12/12/12 at 3:34 PM, the DON (Director of Nursing) was interviewed and stated that the former DON did an investigation for the Human Resources Department that culminated in a written warning for the CNA, with her removal from the resident's floor. She further stated that the investigation should have been thoroughly completed within 5 days.

415.4(b)(1)(ii)

Based on observations, record reviews, and staff interviews, the facility did not ensure that the emergency medication boxes did not contain expired medications. This was evident for 2 of 12 units ( 9th and 15th floor).

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

The findings are:

1) On 12/6/11 at 12:10 pm, during a medication storage observation on the 9th floor, the emergency medication box was observed sealed with an "Emergency Box Master List" that documented the box was checked by the pharmacist on 3/9/11. The list documented that the box contained the following expired medications:
-1 ProAir HFA 90 mcg (micrograms) Aer (Aerosol) w/ Adap (Adapter) inhaler expired 10/30/11
-1 Vitamin K 10mg/ml (milligrams per milliliter) Ampul injection expired 11/1/11

The Registered Nurse (RN) was immediately interviewed and stated that the emergency boxes are checked weekly by the RN or the RN Supervisor for expired medications.

2) During the medication storage tour on the 15th floor on 12/9/2011 at 12:25 PM. The emergency medication box was observed sealed with the label documenting it was last checked 12/3/2010. The emergency box master list documented several expired medications. Upon inspection of the content of the emergency medication box with the unit medication Registered Nurse (RN), it was revealed that following medications had expired on these dates:

Phenytoin Sodium 50mg/1ml 1 vial expired 7/30/2011
Dextrose 50ml 5% IV (intravenous solution) 1 vial expired 7/30/2011
Epinephine 1:1,000 1mg/1ml 1 injection expired 8/01/2011
Vitamin K 10mg/ml 1 injection expired 10/1/2011
Haloperidol 1 ml 5mg/1ml vial 1 injection expired 10/30/2011
Solu-cortel (Hydrocortisone) 100mg 1 vial expired 10/30/2011
Enalapril 5mg 2 tablets expired 10/30/2011
Proair HFA 90 mcg 1 inhalation aerosol expired 11/30/2011

The RN was immediately interviewed and stated that nursing is responsible to check the content list of the emergency medication box to ensure that the box does not contain any expired medications, but this is not done on a particular schedule. In addition, the pharmacist checks the emergency medication boxes and there is no tracking system for pharmacist 's visits.

The Pharmacy Technician was interviewed on 12/13/2011 at 12:34 PM and stated that there is no specific schedule to check the emergency medication boxes. The Technician stated she randomly checks the boxes on units and nurses on all shifts are supposed to do the same, to ensure that the boxes contain no expired medications.

The Director of Nursing was interviewed on 12/13/2011 at 12:40PM and stated that the emergency medication boxes should be checked by the consultant pharmacist monthly per the facility 's contract, but there is no tracking system currently in place. In addition, the in-house pharmacy technician and nurses on all shifts should be checking the boxes to ensure the medications are timely replaced.

Based on record review and staff interview, the facility did not ensure that Physician's orders were followed. Specifically, Nepro and insulin injections were not administered as ordered. This was evident for 2 of 10 residents reviewed for unnecessary medications (Resident #436 and #551).

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

The findings are:

1) Resident #439 is an 86 year old male with diagnoses which include Renal Disease, Adult Failure to Thrive and Hypertension.

The MDS (minimum data set) 3.0 dated 2/9/11 documented that the resident's cognition is severely impaired with long and short-term memory problems.

The Physician's Orders dated 12/8/11 documented Nepro 8 oz (ounces) at 2PM (vanilla) .

Review of the Medication Administration Record (MAR) dated 12/8/11 revealed there was no documented evidence that the Nepro was administered from 12/8/11 to 2/13/11.

Review of the Certified Nursing Assistant Accountability in the handheld PDA (Personal Digital Assistant) revealed there was no documented evidence that the Nepro order was transcribed or administered.

On 12/13/11 at 12:15 pm the LPN (Licensed Practical Nurse) was interviewed and stated that the the CNA (Certified Nursing Assistant) is responsible for the administration of nutrition supplements.

On 12/13/11 at 12:27 pm the RN (registered Nurse) Supervisor was interviewed and stated that the assigned CNA administers the nutrition supplement, as it would appear in the CNA computer system resident profile. She further stated that in this case, the order was not transferred to the CNA's computer system resident profile, therefore the CNA would not know about the supplement.

2) Resident # 551 is an 68 year old male admitted to the facility with diagnoses which include: Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Chronic Pulmonary Embolism, Dementia, Seizure Disorder, Diabetes Mellitus with Feeding and Tracheotomy tubes.

The Minimum data set (MDS 3.0) assessment dated 11/11/11 documented that the resident had short and long-term memory problems and severe cognitive impairment.

The Physician's Orders dated 11/4/11 and 12/3/2011 documented: "Novolg 100 unit/ml (milliters) Sub-Q (subcutaneous) inject by subcutaneous route as per insulin sliding scale protocol...
151-200= 4 units
201-250= 5 units
251-300= 6 units
301-350= 7 units
351-400= 8 units
<70 or >400 inform MD (medical doctor)."

Review of the MAR (Medication Administration Record) from 11/8/11 until 12/12/12/11 documented that no Insulin was administered for the following fingersticks:
6AM 11 AM
11/8/11 182 mg/dl (milligram per deciliter)
12/7/11 191 mg/dl

The MAR further documented that insulin was administered without documentation of the dosage for the following:
6 AM: 11 AM 4 PM: 9 PM
11/9/11 175 mg/dl 162 mg/dl 166 mg/dl
11/11/11 159 mg/dl 153 mg/dl
11/12/11 188 mg/dl 180 mg/dl
11/13/11 166 mg/dl
11/19/11 168 mg/dl 179 mg/dl 166 mg/dl
11/20/11 172 mg/dl
11/23/11 166 mg/dl
11/25/11 166 mg/dl
11/30/11 158 mg/dl
12/1/11 155 mg/dl
12/4/11 166 mg/dl
12/2/11 156 mg/dl
12/9/11 159 mg/dl
12/12/11 199 mg/dl

The Comprehensive "Care Plan Activity Report" entitled "Diabetes Mellitus: IDDM" dated 11/14/11 documented, "...Monitor blood glucose level as ordered....administer medications as ordered."

On 12/13/11 at 12:30PM, the RN Registered Nurse Supervisor, was interviewed and stated that she did not know why the fingerstick orders were not followed. The medication nurses should have been documenting the administration of insulin in the MAR as well as the unit dose to be given according to the sliding scale coverage. She also stated that it is her responsibility to oversee that insulin is being administrated by performing a "scanning review" and a "random spot check" of the medication nurses on certain days.

On 12/13/11 at 1PM, the Licensed Practical Nurse (LPN) medication nurse responsible for administering insulin on 11/8/11, 11/9/11, 11/23/11, 11/28/11, 12/7/11, and 12/12/11 was interviewed and stated that she should document the dosage administered. She added that because of the computer system, she was unable to document the dosages administered.
She further stated that on two separate occasions on 11/11/11 she did not administer insulin to the resident. She stated, "it was my mistake" not to give the insulin as per the doctor's orders.

415.11(c)(3)(ii)

Based on observation, it was determined that the facility did not ensure that exit corridors in the sub-cellar and the corridors on th resident floors are maintained free of combustibles and other miscellaneous storage which would interfere with the safe usage of the corridors during a fire or other emergency. Reference is made to the storage of empty cardboard boxes and cartoned supplies in the corridors leading to stairway "A" and stairway "B" in the sub-cellar; cartoned supplies across from elevators on the 7th floor and numerous items including chairs, hoyer lifts and housekeeping carts on the resident units.

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

The findings include:
On December 6, 2011 and December 7, 2011 at 10:00 AM to 2:30 PM, it was observed that empty cardboard boxes and cartoned supplies were stored adjacent to stair "B" and stair "A", in the sub-cellar. On the 7th floor approximately 10-12 cartons of supplies were observed stored across from the elevator from 10:15 AM to 2:00 PM. Also, on the resident units, corridors were being used for the storage of empty chairs, hoyer lifts and housekeeping carts. Examples are on floor #s 15, 13, 12, 11, 10 and 4. The storage in the exit corridors would make the corridors impassable in case of fire or other emergency. All means of egress are to be maintained free of any storage which would interfere with the safe usage of the egress paths by the occupants of the building. On December 6, 2011 and December 7, 2011 at approximately 2:00 PM, the facility's director of building services stated that staff will be instructed to keep the corridors free of storage of items which are not in use.

711.2(a)(1)ne

Based on observation, it was determined that the facility did not ensure that the corridor doors to resident rooms are maintained free of impediments to closing in their frames. Reference is made to the metal hooks with decorative wreaths placed over the top edge of the doors to room #'s 301, 325, and 303.

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

The findings include:
On December 6, 2011 at 10:00 AM to 2:30 PM, it was observed that the facility used metal hooks over the top edge of doors to hang decorative floral wreaths. Examples include room #s 301, 325 and 303. The metal hooks prevented the doors from closing in their frames. On December 6, 2011 the facility's director of building services stated that all metal hooks over the doors were being removed and that staff is being instructed not to place the hooks over the doors.

711.2 (a)(1)

Based on observation, it was determined that the facility did not en sure that fire doors to the storage rooms are only held open with approved automatic release devices activated via the fire alarm systems of the facility as per 7.2.1.8.2 and 19.2.2.2.6. Reference is made to the door to the central supply room in the sub-cellar that was held open with a chock and the door to the housekeeping storage/office storing hazardous quantities of cartoned supplies in the sub-cellar that was held open with a marble like brick wedged under the door.

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

The findings include:
On December 6, 2011 at 10:00 AM to 2:30 PM, it was observed that the fire door to the central supply storage room in the sub-cellar was held open with a chock wedged under the door. The fire door to the storage room/housekeeping office storing hazardous quantities of cartoned supplies in the sub-cellar was also held open by means of a marble like brick that was wedged under the door. These door hold open devices are not the automatic door releasing devices which will activate upon the activation of the facility's fire alarm systems, sprinkler system and the smoke detection system required under LSC 19.1.4.3, 19.2.2.6 and 7.2.1.8.2. The doors to the hazardous areas (storage areas) can only be held open by approved automatic door hold open devices actuated by the facility's fire alarm systems as described under 7.2.1.8, and 19.2.2.6. On December 6, 2011 at approximately 11:30 AM, the facility's director of building services stated that the facility staff is being instructed to remove the chocks and other items wedged under the doors to the hazardous areas and to keep the doors closed at all times.

711.2 (a)(1)

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that oxygen cylinders stored in the central oxygen storage room on the first floor are separated from combustible paper sheets hung on the storage room walls, as per NFPA 99, Health Care Facilities, 1999.

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

The findings include:
On December 6, 2011 at 10:00 AM to 2:30 PM it was observed that the facility constructed a central oxygen cylinder storage room off the loading dock on the first floor. The storage room was noted to contain approximately 20-25 cylinders of "K" type oxygen cylinders and 20-30 "E" type oxygen cylinders. A stack of 8 inch x 11 inch loose paper sheets and a stack of 15-20, 8 inch x 11 inch paper sheets in a clipboard were observed hanging on the walls of the oxygen storage room. A number of thick paper light bulb-wrappers were also stored on a small shelf within the oxygen storage room. Combustible materials including paper cannot be stored or kept near oxygen cylinders as per NFPA 99. On December 6, 2011 at approximately 12:00 PM, the facility's director of building services stated that all paper items will be removed from the oxygen cylinder storage room.

711.2 (a)(1)

NYCRR 713-1.18(d)(2)(i): Outdoor air intakes shall be located as far as practical but not less than 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vent stacks, or from areas which may collect vehicular exhaust and other noxious fumes. The bottom of outdoor air intakes serving central systems shall be located as high as practical but not less than six feet above ground level or if installed above the roof, three feet above roof level.

This requirement is not met as evidenced by:
Based on observation and staff interview , it was determined that the facility did not ensure that the outdoor air intake louvers for the ventilation equipment located on the roof are a minimum of 25 feet from the toilet plumbing stacks. Reference is made to the air intake louvers for the AC1 and AC2 ventilation equipment for the resident unit corridors which are only 16 feet from the toilet plumbing stack.

The findings include:
On December 6, 2011 at 10:00 AM to 2:30 PM, it was observed that the facility installed air supply ventilation equipment for resident corridors identified as AC1 and AC2 on the roof. The outdoor air intake louvers for the ventilation equipment are located approximately 16 feet from the toilets' plumbing stack instead of the minimum of 25 feet. On December 6, 2011 at approximately 1:00 PM, the facility's director of building services stated that the plumbing stack outlet will be raised above the air intake louvers level for the AC1 and AC2. This will ensure that the plumbing stack soiled air will not return back into the air intake louvers system.

711.2 (1)(a)