Ozanam Hall of Queens Nursing Home Inc

Based on staff interviews and record review during the recertification survey the facility did not ensure that there were specific physicians orders written for the provision of specialized rehabilitation services. Specifically, the Director of Rehabilitative Services interpreted a signed Physical Therapy/Occupational Therapy (PT/OT) evaluation with a treatment plan as physician's orders for rehabilitative services and did not obtain specific orders defining the type of services (Restorative vs. Maintenance), the frequency of services, nor the duration of services. This resulted in no actual harm with potential for minimum harm.

The finding is:

Resident #20, with diagnoses including Osteoarthritis, Diabetes Mellitus and a history of Femur Fracture, was admitted to the facility on 6/02/2011.

The Admission physician's orders dated 6/02/2011 documented a PT and OT Evaluation/Re-evaluation and treat accordingly.

The PT evaluation dated 6/02/2011 documented treatment program consisting of Restorative PT 5 times per week for at least 30 minutes per session for a estimated duration of 4-5 weeks. The treatment plan included but was not limited to: therapeutic exercise, Range of Motion exercises, balance and mat activities, progressive ambulation activities and modalities including moist heat. The PT evaluation was signed and dated 6/02/2011 by the PT. The physician signed the evaluation however there was no date indicating when the physician signed the evaluation.

The Physical Therapy Discharge Summary dated 6/30/2011 documented to discontinue PT and recommended nursing rehabilitation for ambulation 50 feet with a rolling walker and minimal assistance of one person and to follow with a wheelchair. This discharge summary was signed by the physician however it was undated.

The Occupational Therapy evaluation dated 6/02/2011 documented a treatment program consisting of Restorative OT 5-6 times per week for a minimum of 30 minutes per session for an estimated duration of 4 weeks. The treatment plan included but was not limited to: self care activities, balance activities, bed and wheelchair mobility. The OT evaluation was signed and dated 6/02/2011 by the OT. The physician signed and dated the OT evaluation 6/09/2011, seven days after the OT evaluation was completed.

The OT Discharge Note dated 7/16/2011 documented that the resident has received the maximum benefit and that no further progress anticipated. The recommendations were to encourage the resident to participate in Activities of Daily Living (ADL) as tolerated. The OT discharge note was signed by the physician however was undated.

Review of the physician's orders from admission 6/02/2011 through 9/01/2011 revealed that there was no orders written for either the initiation or discontinuation of PT or OT services.

The Comprehensive Care Plan (CCP) for Alteration in ADL's dated 6/03/2011 included interventions of PT and OT as per plan. There was no specific information related to the type, frequency or duration of Rehabilitative Services documented on the CCP. Additionally, there was no documentation on the CCP when services were initiated or discontinued.

An interview was held on 9/07/2011 at 12:03 PM with the Registered Nurse (RN) nurse manager for Resident #20. The RN stated that when a resident is placed on PT/OT/(Speech Therapy) ST program there is no specific physician order obtained. The RN stated that the therapist writes their recommendations on the evaluation and the MD signs the evaluation. The RN further stated that PT/OT/ST does not obtain a specific order to discontinue services.

An interview was held on 9/07/2011 at 12:07 PM with the Rehabilitation Director, who was a Physical Therapist. The PT stated that she interprets the physician's order to "treat accordingly" as appropriate because the physician signs the evaluation which documents the specific treatment plan. The PT further stated that the facility had an audit performed in July or early August 2011 by an outside entity which recommended that specific physician's orders should be obtained for rehabilitative services. The PT stated that she was working on implementing this change but has not done so yet because she is working on revising the policy/procedure for Rehabilitative Services.

An interview was held on 9/07/2011 at 2:41 PM with the Medical Director. The Medical Director stated that he knew the independent audit done sometime in July or August recommended changes regarding more specific physician's orders related to Rehabilitative Services but the changes have not been implemented yet. The Medical Director further stated that the Rehabilitation Director was working on revising the policy/procedure.

An interview was held on 9/07/2011 at 4:15 PM with the Administrator. The Administrator stated that she was aware that the independent audit revealed a concern with Rehabilitative Services but she was not aware of the specific concern until today, 9/07/2011.

415.16(b)

Based on observation and staff interview during the recertification survey, the facility did not ensure that corridor walls were constructed to resist the passage of smoke and constructed with at least one half hour fire resistance rating. This was evidenced by unsealed penetrations of the corridor walls in the East wing electrical closets on 9 of 9 resident sleeping floors.

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

The findings are:

During life safety inspections on 09/01/11, and 09/02/11, between 9:00am and 2:00pm, an unsealed 6 inch diameter metal sleeve was observed in each of the East wing electrical closets on resident sleeping floors 2 through 10. The metal sleeves were noted to have penetrated the corridor walls within the electrical closets and were not completely sealed around the wires that passes through them.

In an interview on 09/01/11 at approximately 11:00am the Director of Engineering stated that the metal sleeves contained data and telephone cables and were supposed to be sealed by the outside contractors. He immediately contacted a maintenance employee to start sealing the identified unsealed metal sleeves and stated that the issue would be discussed with the Administrator in order to be addressed and to prevent it from occurring in the future.

NYCRR 711.2(a)
10 NYCRR 415.29

Based on observation and staff interview during the recertification survey, the facility did not ensure that doors protecting corridor openings are maintained to resist the passage of smoke/fire, and provided with the means suitable for keeping them closed on 8 of 9 resident sleeping floors.

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

The findings are:

During life safety inspections on 09/01/11, and 09/02/11, between 9:00am and 2:00pm, the following was noted:

1. The following corridor doors did not positively latch when tested:

- The 10th floor staff locker room door did not have a door closure device was not installed on the door and did not positively latch when it was released from the open position.
- The 10th and 6th floor North wing clean linen rooms and the 4th floor North wing mechanical lift storage room doors were noted with inactive leaves that were not latched and did not afford the active leaves to positively latch.
- The 5th and 4th floor North wing equipment storage room doors were obstructed from closing/positive latching by jamming on the door frames.
- The 5th floor nurses lounge room door did not did not positively latch when released from the open position. There was an approximate 3 inch gap between the meeting edges of the door and doorframe.
- The 4th floor 3rd floor East wing soiled utility room doors did not positively latch when released from the open position. There was an approximate 2 inch gap between the meeting edges of the doors and door frames.

2. The 2nd floor North wing clean linen corridor door was observed with transfer grilles. The transfer grilles were observed not sealed on either sides of the door.

In an interview on 09/01/11 at approximately 10:45am, the Director of Engineering stated that the identified issues with the corridor doors would be addressed. He stated that the employees on the units are supposed to report issues with the doors and that he is not aware of the doors not being positive latching. He further stated that the transfer grilles on the identified door would be sealed.

NYCRR 711.2(a)
10 NYCRR 415.29

Based on observation and staff interview during the recertification survey the facility did not ensure that the smoke barriers are maintained with a fire resistance rating of at least 30 minutes and were capable of resisting the passage of smoke. Reference is made to unsealed penetrations of the smoke barriers above the smoke barrier doors on 9 of 9 resident sleeping floors.

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

The findings include but not limited to:

On 09/01/11 and 09/02/11 during the Annual Recertification Survey the following penetrations were observed at the smoke barrier walls above the double doors:

Unsealed and improperly sealed cable and conduit penetrations were observed above the double smoke barrier doors in the vicinity of resident room 936.

Unsealed couduit penetration with approximately 3/4 inch annular space and a metal conduit with approximately 4 inch annular space were observed in the vicinities of resident room #s 736 and 730 on the 7th floor.

Unsealed wire penetration was found above the smoke barrier wall in the vicinity of room 501 on the 5th floor.

In an interview on the same day at approximately 10:00am, the Director of Engineering stated that the unfilled penetrations of the smoke barriers were probably left by the outside contractors during routine maintenance. He further stated that all the outside contractors are usually briefed about sealing penetrations of the smoke barriers with fire stopping material and that the issue would be discussed with the Administrator in order to be addressed. He further stated that he is unaware of the unsealed penetrations and immediately contacted a maintenance employee to start sealing the identified unfilled penetrations.

711.2(a)(1)

Based on observation and staff interview during the recertification survey the facility did not ensure that smoke detectors, at the minimum of battery powered, were installed in all required locations for an existing facility that is not fully sprinklered.

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

The findings are:

During life safety inspections on 09/01/11, and 09/02/11, between 9:00am and 2:00pm, it was noted that the nursing home building is partially sprinklered and the required smoke detectors, at minimum battery operated smoke detectors, were not provided in the Sunburst Parlor and the Chapel located on the 1st floor. Residents were observed congregating in the identified areas during the survey.

In an interview on 09/02/11 at approximately 10:00am, the Director of Engineering stated that battery operated smoke detectors would be provided in the identified areas. He further stated that the smoke detectors were removed from the Chapel because they were accidentally activated during prayer services in the past. He also stated that the residents have unimpeded access to the Chapel and Sunburst parlor.

NYCRR 711.2(a)
10 NYCRR 415.29

Based on observation and interview it was determined that the facility failed to indicate the way to an exit discharge in that directional sign was not provided from the dietary and central supply areas to an egress access in accordance with Section 7-10. This was observed in the basement.

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

The Finding is:

On September 2,2011 during the Annual recertification survey, it was observed that exit directional sign(s) from the central supply and dietary storage areas to the corridor was not provided. It was not clear to the surveyor which of the doors from the area could be used as an exit in the case of fire or other emergency.

In an interview with the Maintenance/Engineering Director on 09/2/11 at approximately 10:40 AM, he stated that exit signs will be placed immediately in the required areas.
2000 NFPA 101 LSC; 19.2.10, 7.10
10NYCRR 711.2
NYCRR 415.29