New Vanderbilt Rehabilitation and Care Center, Inc

Based on observations, record reviews and staff interviews, the facility did not ensure that the resident received a pressure relieving device for a pressure ulcer located on the right heel. This was evident for one of 30 sampled residents, resident #18.

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

The finding is:

Resident #18 is 56 years old with diagnoses that include: Right Heel Gangrene, Diabetes and Obesity.

The Minimum Data Set dated 11/8/2010 documents that he is dependent upon the staff for all aspects of daily living.

On 12/20/10 at approximately 2:50 PM, the resident was noted in bed with the right heel on the mattress and the left leg flexed at the knee and side-lying while in bed.

On 12/21/10 at approximately 10:10 AM prior to the dressing change observation of the sacral area, it was observed that the resident did not have Spanco booties on his feet when the Certified Nurse's Aide (CNA) pulled the sheet away that covered the resident.

On 12/22/10 at approximately 10:45 AM, the resident's right heel was observed without Spanco booties prior to the Licensed Practical Nurse performing the dressing change to the right heel. The CNA (#1) that was assisting the LPN stated that the resident did not have Spanco booties on when she checked him at the beginning of her shift.

On 12/22/10 at approximately 11:10 AM, the resident was observed following a transfer to a Geri-chair without Spanco booties on his feet.

On 12/22/10 at approximately 12:30PM, the resident was observed while in the Geri-chair without Spanco booties on his feet.

The Comprehensive Care Plan for Skin Integrity dated 6/7/10 documented Spanco boots in bed. This care plan was revised on 9/27/10 and documented to continue with goals and approach.

A review of the December 2010 CNA Accountability Record and Assignment from 12/1/10 to 12/23/10 documents: Bilateral Spanco Booties to lower extremities. This form did not document that the Spanco boots were applied 12/2/10 to 12/3/10 and 12/13/10 to 12/23/10 (12 days).

On 12/22/10 at approximately 3:30PM the Registered Nurse Manager and this surveyor checked the resident's room. The Spanco booties could not be located and the resident was not wearing them on his feet. The RN manager immediately obtained a pair of booties for the resident and they were placed on his feet. She stated that she is sure that the resident always wears the booties.

On 12/23/10 at approximately 10:35 Am the LPN was interviewed and stated that he could not recall if the Spanco booties were present on 12/21/10 when he performed the dressing change of the right heel. He further stated that he told the CNA (#2 who assisted him on 12/21/10) to put them on the resident and that she did not report that the resident did not have the booties.

He continued to state that on 12/22/10 he instructed CNA #1 to put the Spanco booties on the resident but did not check to see that they were in place.

On 12/23/10 at approximately 12:40 PM CNA #1 was interviewed and she stated on 12/22/10 she checked the CNA Assignment and knew he needed them. When she checked the resident's room she realized they were not there. She went to the LPN and she was told they were not available. She thought the LPN would obtain them.

415.11(c)(3)(ii)

Based on observations and interview it was determined that the facility did not ensure that exit access ramp located in inside of stairwell "B" was smooth and leveled with the floor as to prevent any tripping hazard.

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

The Findings is:

During the life safety tour on 12/20/10 between 1:00 p.m. and 2:45 p.m., the following was noted:

The exterior exit discharge pathway from stairway "B" led to back of the building. A small ramp was observed on the inside of the stairwell leading to the exit door to outside. Further observations revealed that the ramp was not continuous from the inside of the stairwell to the egress door. There was approximately "1" inch drop between the base of the ramp and the egress door.

In an interview with the maintenance director on 12/20/10 at 2:10 pm, he stated that this concern will be corrected immediately and that the rise will be leveled with the floor.

415.29(a)(1), (2)
711.2(a)(1)
NFPA 101 LSC 2000: 19.2.1

NYCRR Section 713-1.18 - Mechanical requirements
713-1.18 Mechanical requirements

(1) Plumbing fixtures
(ii) The water supply spout for lavatories and sinks required in resident 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 residents and food handlers shall be trimmed with valves, which can be operated without the use of hands. Where blade handles are used for this purpose, they shall not exceed four and one-half inches in length, except that handle on clinical sinks shall be not less than six inches long.

Based on observation and interview, it was determined that the facility did not ensure that the water supply spout provided in hand-washing sinks in the resident units are mounted at a minimum distance of five inches above the rim of the fixture as evidenced by faucets in hand-washing sinks in the resident rooms, treatment room, patient shower area and medication room lacking the required discharge point minimum distance of five inches above the rim of the fixture.

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

The Findings include, but are not limited to:

On 12/20/10 and 12/21/10 between 9:00 a.m. and 2:00 p.m, the hand washing sinks in resident rooms 812,816,818,720,510,patient shower areas, medication room on the 4th floor,treatment room on the 7th floor were noted to have water supply spouts which were mounted such that the discharge point lacked a minimum distance of five inches from the rim of the fixture. They were 2 to 3 inches from the rim.

In an interview on 12/21/10 at approximately 2:30pm, the Director of Engineering stated that these concerns will be corrected immediately.