Flushing Manor Nursing Home

Based on observations, record review and staff interviews, the facility did not ensure that infection control procedures were adhered to during a dressing change observation. Specifically, the Registered Nurse (RN) did not wash hands and change gloves from the cleansing of the wound to the application of the new treatment. This was evident for one (1) of thirty (30) sampled residents. (Residents #14)

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

The findings is:

Resident #14 is a 72 year old female with diagnoses which include Osteomyelitis, Hypertension, and Parkinson's Disease.

The Minimum Data Set 2.0 Assessment dated 12/4/09 documented that the resident had moderate cognitive impairment, and total dependence on staff for transfers, dressing, bathing, and personal hygiene.

The physician's orders dated 2/5/10 documented to cleanse stage IV (four) sacral area with normal saline solution followed by the application of Silver Alginate and dry sterile dressing daily and prn (as needed).

The Registered Nurse (RN) was observed on 2/18/10 at 9:50 a.m. during a wound care observation cleansing the resident's sacral wound with normal saline solution in a repeated back and forth motion several times before discarding the gauze. The RN did not remove her gloves and wash her hands, and proceeded with the application of the Silver Alginate dressing and the dry sterile dressing.

The RN was immediately interviewed and stated that she was taught to wash her hands three times during the entire dressing change procedure, and had not realized that she had not washed her hands after the initial cleansing of the residents sacrum. The RN further stated that she also didn't realize that she had cleansed the wound in a back and forth motion.

The RN Staff Development Coordinator was interviewed on 2/18/10 at 10:30 a.m. The RN stated that the nurses are taught to wash their hands three times but it is the timing of the hand washing that is important. The RN further stated that the nurses are taught to cleanse the wound from the center towards the outer aspect, discard the gauze used for cleansing, remove gloves, wash hands, and then proceed with the application of the prescribed dressings. The RN also stated that she inservices all the nurses on a yearly basis by return demonstration.

The RN Staff Development Coordinator provided the SA (State Agency) surveyor with a copy of the revised policy and procedure for "Wound Dressing/Aseptic Dressing," dated 2/18/10. The revised policy included "remove gloves and discard in plastic bag, wash hands" after cleansing wound and surrounding areas..."

415.19(a)(1-3)

Section 7.2.1.5.1, states that doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Lock, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Based on observation, it was determined that the facility did not ensure that the door to the walk-in refrigerator/freezer, the door to the central supply room, and the door to the laundry area are free of any locking devices which could not be operated from the egress side (inside).

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

The findings include:
On February 16, 2010 and February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the doors to the walkin refrigerator/freezer door to th central supply room, and the door to the laundry area, in the basement, are equipped with padlocks. These locks, if engaged, could not be opened from the egress side (from the inside of the refrigerator, central supply room and the laundry room). The egress doors cannot be equipped with any locking devices which could not be operated from the egress side. On February 18, 2010, at approximately 2:00 PM, during the exit conference, the director of maintenance stated that the padlocks have been removed from the doors to the refrigerator, laundry area and the central supply room.

II. Section 7.2.1.5.4 states that a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches (86 cm) and not more than 48 inches (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the egress doors from the clean linen room and the laundry area are equipped with latching/locking devices which could be released with only one releasing operation from the egress side and that the door releasing devices are the familiar type of releasing devices.

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

The findings include:
On February 16, 2010 and February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the doors to the clean linen room and the laundry area, in the batsmen, are equipped with dead bolt type locks in addition to the conventional door latching device. These door fastening devices, when engaged, would require more than one operation to open the door from the egress side (the twisting of the thumb twist device to open the dead bolt lock and then turning the door knob to release the conventional door latching device). Also, the thumb twist type lock releasing device is not the familiar type lock releasing device and would be difficult to locate and operate during darkness. On February 18, 2010, at approximately 2:00 PM, during the exit conference, the facility director of maintenance stated that the dead bolt locks are being removed from all egress doors.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the exit discharge areas, immediately outside of exit door adjacent to room #114 and room 115/111 are maintained free of accumulation of snow/ice, so as to provide for the free movement of occupants in case of fire or other emergency.

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

The findings include:
On February 18, 2010, at 10:30 AM, it was observed that the exit discharge areas, immediately outside of the exit doors adjacent to room 114 and 115/111, had an accumulation of 2-3 inch thick layer of snow/ice. The accumulation of snow/ice at the exit discharge location would impede the free and safe movement of the building occupants during fire or other emergency. On February 18, 2010, at approximately 2:00 PM during the exit conference, the facility's director of maintenance stated that all exit discharge areas have been cleared of the accumulation of snow/ice.

711.2 (a)(1)

Section 5-2, NFPA10, standard for portable fire extinguishers, states that at intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically retested. The hydrostatic retest shall be conducted within the calender year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified date.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the stored-pressure water type portable extinguishers provided on the 3rd floor are hydrostatically retested at 5 years intervals, s per table 5-2, NFPA 10.

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

The findings include:
On February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the facility has provided water type pressure portable fire extinguisher in the building. At least 2 of the fire extinguishers on the third floor lack evidenceof the hydrostatic test record since their manufacturing year of 2003 (the date shown at the face of the extinguishers). Stored-pressure water type extinguishers must be retested hydrostatically every 5 years and test record be maintained on a suitable metallic label affixed to the extinguisher shell, as per 5-6.4, NFPA 10. On February 18, 2010, at approximately 2:00 PM, the facility's director of maintenance stated that the old extinguishers on the 3rd floor have been replaced with the properly tested extinguishers.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the illumination of the exit discharge area from the South exit stairway leading to Parsons Boulevard, is arranged so as to provide continuous lighting upon failure/burning out of any single lighting fixture or a single bulb.

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

The findings include:
On February 16, 2010 and February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the facility has provided a single bulb lighting fixture at the exit discharge area from the South exit stairway, leading to Parsons Boulevard. Multiple lighting fixtures or a lighting fixture containing multiple bulbs must be installed at the exit discharge area. This would ensure the continuous illumination of the exit discharge area even upon the failure/burning out of any single lighting fixture or any single bulb in a fixture. On February 18, 2010, at approximately 2:00 PM, the facility's director of maintenance stated that all exit discharge areas will be provided with multiple lighting fixtures or the lighting fixture with multiple bulbs will be installed to ensure continuous illumination even upon failure or burning out of any single lighting fixture or the single bulb within the lighting fixture.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the sectional sprinkler control valve located in the basement and serving the sprinkler line for the driveway area/garage area is electrically supervised (fully supervised) so that at least a local alarm will sound when the valve is closed, as per NFPA72 and Life safety code 19.3.5.

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

The findings include:
On February 16, 2010 and February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the facility has installed the electrical supervisory system for the main sprinkler control valves located in the sprinkler control room. The supervisory system registers an audio and visual signal at the first floor, when the valve(s) are closed. Nevertheless, the sectional sprinkler control valve located in the storage area in the basement and serving the driveway/garage area, lacks the electrical supervision so that an alarm will sound at the designated location within the building when the valve is closed. On February 18, 2010, at approximately 2:00 PM during the exit conference, the facility's director of maintenance stated that the sprinkler company is being contacted to install an electrical supervisory system on the sprinkler control valve serving the driveway area.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the oxygen cylinders stored within the nursing storage area, on the first floor, are separated from the combustible material/storage (cardboard boxes, cartoned supplies, and miscellaneous combustible packages), as per 8.3.1.11.2, NFPA99 - Health Care Facilities.

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

The findings include:
On February 18, 2010 at 9:30 AM to 2:00 PM, it was observed that in the nursing supply storage room on the first floor, approximately 11 "E" size oxygen tanks were stored adjacent to and in close proximity to the storage shelves storing cardboard boxes, cartoned supplies and miscellaneous combustible packages. Oxygen storage must be separated from combustible storage, in accordance with NFPA99 - Health Care Facilities Code. On February 18, 2010, at approximately 2:00 PM, during the exit conference, the facility's director of maintenance stated that the oxygen tanks will be stored separate from the combustible supplies.

711.2 (a)(1)

Section 5.2.1.1.1, NFPA25, requires that the sprinklers shall not show signs of leakage, shall be free of corrosion, foreign material, paint, and physical damage; and shall be installed in the proper orientation (e.g. upright, pendent, side wall).

Based on observation, it was determined that the facility did not ensure that sprinklers installed in the maintenance shop in the basement are in the proper orientation.

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

The findings include:
On February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that in the basement within the maintenance shop, at least two sprinkler heads are installed in the pendent position. These sprinkler heads are, however, designed to be installed in the upright position instead of the pendent position.On February 18, 2010 at approximately 2:00 PM, during the exit conference, the facility's director of maintenance stated that the sprinkler heads in the maintenance shop have been changed to their proper orientation.

711.2 (a)(1)

NYCRR 713-1.18 (d)(2)(vi)(a)
(a) Filter frames shall be durable and carefully dimensioned and shall provide air-tight fit with the enclosing duct work. All joints between filter segments and the enclosing duct work shall be gasketed or sealed to provide seal against air leakage.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the filter segments provided for the air handling equipment (air supply equipment) serving the kitchen areas in the basement, are constructed with durable frames and are properly dimentioned and fitted in the enclosed duct work to provide a tight seal against air leakage.

The findings include:
On February 16, 2010 and February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the facility is using the throw-in type woven filters for the air handling unit serving the kitchen areas in the basement. The end filter segment, adjacent to the filter access panel, was noted with no filter frame. The woven filter material was loosely filted with the enclosed duct work wall and filter track. This type of filter would not provide a tight seal against air leakage. On February 18, 2010 at approximately 2:00 PM, during the exit conference, the facility's maintenance director stated that the filter was installed as a temporary measure, until properly framed filter was purchased. The director further stated that properly dimensioned filters with durable frames are being installed in the air handling equipment for the kitchen.

NYCRR 713-1.18(d)(vi)(b)
A manometer shall be installed across each filter bed serving central air systems.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that a manometer is installed across the filter bed serving the central air handling equipment unit for the kitchen areas.

The findings include:
On February 16, 2010 and February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the facility has provided series of throw- in type filter for the air handling unit (air supply unit) for the kitchen area. The filter bed for the air handling unit lacks a manometer. On February 18, 2010, at approximately 2:00 PM, the facility's director of maintenance stated that the mechanical company will be contacted to install a manometer for the air handling unit serving the kitchen areas.

NYCRR 713-1.18(e)(1)(ii)
The water supply spout for lavatories and sinks required in patient care areas shall be mounted so that its discharge point is a minimum distance of five inches above the rim of the fixture.All fixtures used by medical and nursing staff, and all lavatories used by patients and food handlers shall be trimmed with valves which can be operated without the use of hands . W here blade handles are used for this purpose, they shall not exceed four and one-half inches in length, except that handles on clinical sinks shall be not less than six inches long.

This Requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not e nsure that the handwashing sink in the toilet room of the beauty shop in the basement, is provided with valves which could be operated without the use of hands.

The findings include:
On February 16, 2010 and February 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the handwashing sink in the staff toilet room, off the beauty shop in the basement, is equipped with round type valves. The wrist blade type valves, which could be operated without the use of hands, were lacking at the sink. On February 18, 2010, at approximately 2:00 PM, the facility's director of maintenance stated that the wrist blade type valves will be installed at the handwashing sink.