Ozanam Hall of Queens Nursing Home Inc

Based on observations and resident and staff interviews during the recertification survey, the facility did not ensure that one of thirty sampled residents with physical limitations was accommodated with an adaptive call bell (Resident #17). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #17 has diagnoses including Right Hemiplegia and Cerebral Vascular Accident (CVA).

An Admission Minimum Data Set (MDS) dated 11/15/09 documented that the resident had no functional limitations in voluntary movement of the arms or hands.

A Significant MDS dated 5/24/10 documented that the resident now had partial loss of voluntary movement of the arm and hand.

An observation was made on 9/2/10 at 11:30 AM of Resident #17, who was seated in a wheelchair visiting with her family member. Resident #17 was noted to have contractures of the right hand. Resident #17's family member stated that the resident was unable to use the call bell.

A Comprehensive Care Plan titled Pain and dated 1/10/10 documented an Environmental Adaptation Intervention of a call bell within reach. The CCP further documented that the resident returned from the hospital on 5/17/10 with a diagnosis of CVA with hemiparesis.

A CCP titled Alterations in Activities of Daily Living (ADL) dated 11/9/09 documented that the call bell is to be within easy reach.

A Certified Nursing Assistant Assignment Record (CNAAR) dated 6/28/10 documented that Resident #17 was unable to use the call bell.

An Occupational Therapy (OT) note dated 8/13/10 documented that the resident was seen regarding Left Upper Extremity function, which remains impaired and that OT intervention was not indicated at this time.

An interview with the resident and a family member on 9/2/10 at 12:30 PM. Both stated that the resident was not able to use the call bell button because of her hands dexterity impairment. The resident further stated that she just has to wait for her CNA to come by her room to ask for any assistance. The resident also stated that the wait could take at least 2 hours during the night shift.

An interview was held with the CNA on 9/9/10 at 10:30 AM. The CNA stated that the resident could press the call bell button whenever she needs assistance. However, on observation at this same time, the resident, who was in bed, was observed not to be able to manipulate or press the call bell button when attempted. The resident then stated that she was not able to press the call bell button.

An interview was held with the OT Director on 9/9/10 at 11:00 AM. The Director stated that a sensor pad should have been provided to the resident instead of the call bell button instrument.

415.5(e)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a Comprehensive Significant Change Assessment was completed after the facility should have determined there was a significant change in a residents physical condition. This was evident for one resident in a total of 30 sampled (Resident #3). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #3 was admitted to the facility on 4/8/10 with diagnoses including Status Post Fall with Right Pelvic Fracture and Gait Disorder.

A Comprehensive Care Plan (CCP) titled ADLs/Falls dated as initiated on 4/8/10 documented that the resident had alterations in Activities of Daily Living (ADL) secondary to Status Post Fall with Left Pelvic Fracture and that the resident was at risk for a decrease in ADL. Interventions documented on 4/8/10 included: Range of Motion (ROM) Program, Devices as directed and call bell within reach.

A Minimum Data Set (MDS) Assessment dated 4/14/10 documented that the resident was moderately impaired with cognitive skills for daily decision making and had both long-term and short-term memory problems. The MDS also documented that the resident required staff supervision and no set-up or physical help with the following ADLs: bed mobility, transferring, walking in room, walking in corridor, locomotion on and off unit. The MDS also documented that the resident had no limitations or losses in functional limitation in ROM.

An Integrated Progress Note (IPN) dated 5/13/10 at 11:30 PM documented that the resident had sustained a fall and was transferred to the hospital to Rule Out Fracture.

An IPN dated 5/14/10 at 6:00 AM documented that the resident had returned to the facility Status Post Left Humerus Fracture.

An Occupational Therapy Note dated 6/11/10 documented that Resident #3 was discharged from therapy because they have reached their maximum benefit.

A Quarterly MDS Assessment dated 6/12/10 documented that the resident required Extensive Assistance of one staff member to complete the following ADLs: bed mobility, transferring, walk in room, walk in corridor and locomotion on unit. The MDS documented that the resident was totally dependent of one staff member for locomotion on unit. The MDS also documented that the resident now had partial loss of voluntary movement of their arm and hand in the section titled functional limitation in ROM.

The CCP titled ADLs/Falls dated 4/8/10 was not updated to address the documented decline in ADLs and in functional limitation in ROM as identified on the MDS dated 6/12/10.

An interview was conducted on 9/8/10 at 11:00 AM with the Director of Quality and Risk Management. The Director stated that she was responsible for coordinating the MDS completion throughout the facility. The Director stated that she had not been made aware by the Registered Nurse (RN) who had completed the 6/12/10 MDS that multiple changes in ADLs had been noted for Resident #3. The Director stated that a Comprehensive Significant Change MDS Assessment should have been completed for Resident #3 within 14 days of identifying 3 or more changes in her physical status.

An interview was conducted on 9/8/10 at 1:45 PM with the RN who had completed both the 4/14/10 and 6/12/10 MDS Assessments. The RN stated that she did recall notifying the Director of Quality and Risk Management that Resident #3 had presented with several changes when she completed the 6/12/10 MDS Assessment. The RN also stated that the Director had told her that no change in condition documentation was needed because the resident was expected to improve.

415.11 (a) (3) (ii)

Based on observations and staff interviews during the recertification survey, the facility did not ensure that the Infection Control Program was maintained in a manner to help prevent the development and transmission of disease and infection for one of four medication nurses observed for the medication administration observations. Specifically, Registered Nurse #1 administered her medications without washing her hands or using a sanitizing gel prior to or after touching Residents #38, #39, and #40. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

A medication administration observation with a Registered Nurse (RN) was conducted at the 8th Floor Unit on 9/2/10 at 9:35 AM.

The RN was observed to have prepared Resident #38's medication in a medication souffle cup after the RN touched the resident to check the identification band. The RN then wheeled the resident in a wheelchair into a treatment room to obtain the resident's blood pressure.

The RN then proceeded to wheel the resident back into the hallway and to administer her medication.

Resident #39, who was noted to be confused as to where she was going, was noted alongside the RN's medication cart. The RN redirected and guided the resident by her hand back to her room located about 6-8 feet from where the medication cart was parked. The resident was observed to be restless and wanting to come out of her room. The RN again guided Resident #39 to the nearby Day Room and seated the resident on a chair to mingle with the rest of the residents watching the morning television show.

The RN did not washed her hands or utilize a sanitizing gel after touching Residents #38 and #39. The RN then proceeded to administer Resident #38's medications.

The RN proceeded to prepare Resident #40's medication. The RN administered the medication without washing her hands or using a sanitizing gel prior to preparation of the medication or after touching Resident #39.

The RN was interviewed immediately after the observation and stated "I'm forgot to wash my hands".

The Infection Control RN was interviewed on 9/3/10 at 10:00 AM. The RN stated that hand washing should have been instituted after touching the residents and administering each residents' medications.

The facility's policy revised 08/2009 titled Hand Washing documented "Hand hygiene is indicated using the CDC (Center for Disease Control)Guidelines..."

415.19(a)(1-3)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that all injuries of unknown origin were fully investigated to rule out abuse, neglect or mistreatment. This was evident for 2 of 14 residents reviewed for Falls/Fractures in a total of 30 sampled residents. Specifically, 1) Resident #19 had two separate incidents documenting ecchymotic areas of unknown source: a) on 6/26/10 to the right forearm and b) 8/10/10 to the right forehead. There were no documented staff interviews related to the incidents to rule out abuse, neglect or mistreatment; 2) Resident #30 was documented to have had two incidents of ecchymotic areas of unknown source a) on 1/22/10 to the right hand and b) 6/30/10 to the right foot, without documented interviews from appropriate staff on the prior shifts. This resulted in no actual harm with the potential for more than minimal harm which is not immediate jeopardy.

The findings are:

1a) Resident #19 has diagnoses which include Dementia with Psychosis and Depression.

The Minimum Data Set (MDS) Assessment dated 4/20/10 documented that the resident had severely impaired cognitive skills for daily decision making. The MDS also documented that the resident was totally dependant on staff for all care needs and had behavioral symptoms which included socially inappropriate/disruptive behaviors and resisted care.

A Nursing Progress Note dated 6/26/10 at 8:30 AM documented that an ecchymotic area on the resident's right forearm was reported to the Unit Registered Nurse (RN) by the Certified Nursing Assistant (CNA) who was delivering care.

The resident was examined by the Nurse Practitioner (NP) on 6/28/10 at 8:00 AM and the NP documented that the resident had an ecchymotic area to the right forearm and wrist measuring 6 centimeters (cm) x 5.5 cm.

A facility Occurrence/ Incident (O/I) Report dated 6/28/10 at 8:30 AM documented that the CNA noted an ecchymotic area on the resident's right forearm. There were no statements obtained from any of the CNAs who cared for the resident on any prior shifts. The O/I did not document that abuse/neglect or mistreatment was ruled out.

1b) The MDS Assessment dated 7/12/10 documented that Resident #19 had severely impaired cognition and was totally dependant on staff for all activities of daily living. The MDS documented that the resident was dependant on two staff members for bed mobility and transfer.

An O/I Report dated 8/10/10 at 8:35 AM documented that the CNA reported that the resident was noted with an ecchymotic area to the right side of the resident's forehead measuring 3.0 cm x 2.5 cm.

There were no documented statements obtained at the time of the investigation on 8/10/10 from the staff who had assisted with the resident's care on the prior shifts.

The 8/10/10 O/I Report did not document if abuse/neglect or mistreatment was ruled out.

The Director of Nursing Services (DNS) was interviewed on 9/9/10 at 11:30 AM. The DNS stated that she had been unable to locate statements related to the O/Is for Resident #19. The DNS further stated that the O/I Reports should have been completed and appropriate statements should have been obtained.

2a) Resident #30 has diagnoses which include Osteoporosis and Cerebral Vascular Disease.

A facility O/I Report dated 1/22/10 at 10:00 PM documented that while providing care the resident's CNA observed ecchymotic areas to the resident's right hand measuring 3.5 cm x 3.0 cm and right shoulder measuring 3.0 cm x 2.0 cm.

The Annual MDS Assessment dated 1/30/10 documented that the resident's cognition was moderately impaired for daily decision making. The MDS also documented that the resident was totally dependant on staff for all activities of daily living and required the assist of two staff for bed mobility and transfer with a mechanical lift.

There was no documented statements from any staff who had assisted with the resident's transfer and positioning on the 3:00 PM-11:00 PM Shift on 1/22/10 when the ecchymotic areas were noted. In addition, there were no statements documented from any staff who provided care on the prior two shifts.

2b) A facility O/I Report dated 6/30/10 at 11:00 AM documented that an ecchymotic area located on Resident #30's right foot was noted by the CNA providing care.

The Nursing Progress Note dated 6/30/10 at 3:00 PM documented that the ecchymotic area on the right foot measured 5 cm x 4 cm.

The 1:00 PM Progress Note on 6/30/10 documented that an X-Ray was completed of the right foot to rule out a fracture.

There was no documented statements from any staff who had assisted with the resident's transfer and positioning on the 7:00 AM-3:00 PM Shift on 6/30/10 when the ecchymotic area was noted. In addition, there were no statements documented from any staff who provided care on the prior two shifts.

During an interview with the DNS on 9/9/10 at 11:30 AM, the DNS stated that it is policy to always get CNA statements and, and she was unable to locate any statements. The DNS stated that it is facility protocol to get statements from both CNAs involved in a two person transfer.

415.4(b)(1)(ii)

7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

This REQUIREMENT is not met as evidenced by:

Based on observation and staff interview the facility did not ensure that exit accesses were provided with readily visible exit signs indicating the nearest exits for the elevator lobbies on 2 of 10 resident use floors.

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

The findings are:

During the recertification survey on 09/02/10 between 8:30am and 3:00pm it was observed that approved exit signs were not provided at the East and West corridor intersections on floors 2 to 10 pointing to the nearest exit from the elevator lobbies. Only one exit sign each was provided at the elevator lobbies directing egress towards the East exit stairwell.

In an interview at approximately 10:00am the Director of Engineering stated that the exit signs would be installed in the identified areas. He further stated that the exit signs may have been removed and never reinstalled in the areas after the renovations.

NYCRR 711.2(a)(1)
2000 NFPA 101
10 NYCRR 415.29

1998 NFPA 17A- Standard for Wet Chemical Extinguishing Systems
5.2 Owner's Inspection.
5.2.1
Inspection shall be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

This REQUIREMENT is not met as evidenced by:

Based on observation, staff interview and record review it was determined that the facility did not conduct monthly inspections for 2 of 2 wet chemical range hood fire suppression systems (Ansul). This was evidence by a lack of an up to date monthly inspections as indicated on the inspection tags and the facility supplied documentation for the Ansul systems. This was observed in the main kitchen and the Caf.

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

The findings are:

During the recertification survey on 09/02/10 between 8:30am and 3:00pm it was observed that the facility's main kitchen and the Caf are equipped with wet chemical fire suppression systems (Ansul systems). Observations of the service tags on the Ansul systems revealed that they were not inspected monthly since the last service date of April 2010. A review of the facility's inspection list of fire extinguishers could not verify that the monthly inspections were completed for the two Ansul systems. There were no monthly inspection dates indicated on the extinguisher list for the Ansul systems.

2000 NFPA 101- 19.3.2.6, 9.2.3
1998 NFPA 17A- 5.2.1, 5.3.1.1
NYCRR 711.2(a)(1)
10 NYCRR 415.29