Clinton County Nursing Home

Deficiency Details, Complaint Survey, August 2, 2010

PFI: 0144
Regional Office: Capital District Regional Office

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F279 483.20(d), 483.20(k)(1): DEVELOP COMPREHENSIVE CARE PLANS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: September 15, 2010

A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4).

Citation date: August 2, 2010

Based on medical record review and staff interviews during a complaint investigation (Case #NY00087041), it was determined that the facility did not ensure that a Comprehensive Care Plan (CCP) for one (Resident #2) of 4 residents reviewed. Specifically, the facility did not develop a care plan that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. Additionally, the facility did not provide an environment where 2 residents (#s 3 and 4), felt safe in their environment and felt that their personal property was secure. This is a repeat deficiency from the standard recertification survey of 10/29/09. This resulted in no actual harm with the potential for more than minimum harm that was not immediate jeopardy. This was evidenced by the following:

1. Resident #2
The resident was admitted to the facility on 11/05/09 with diagnoses of dementia, hypertension and diabetes mellitus. The Minimum Data Set (MDS) dated 4/23/10 assessed the resident as having impaired long and short term memory and moderately impaired decision making ability. The MDS also documented that the resident displayed daily wandering type behavior that was not easily altered.

Resident #2's CCP dated 2/9/10 and the Certified Nurse Aide (CNA) care card (not dated)(information used by the CNAs to provide care to individual residents), not dated revealed there was no intervention for Resident #2's repeated behavior of placing her hands inside of her pants/pull-ups and there was no mention of screens being placed across other resident's doors to prevent Resident #2 from entering resident rooms. The CNA care card instructed the CNA caring for the resident to check on the resident only every 15 minutes to monitor her whereabouts.

During an interview on 6/18/10 at approximately 9:00 am, the Director of Nursing (DON) stated that Resident #2 had a history of wandering into other resident's rooms and taking food items off of their trays and personal items out of their rooms. The resident also had a habit of placing her hands down inside of her pants. The DON stated that the resident had been checked for irritation in the groin and peri area and there was no irritation noted. The DON stated that the resident was now being placed in a TV lounge area when the food trays arrived on the unit and explained that the resident stayed in this area until the trays were removed from the unit. The DON explained that the room had a half or dutch door and glass walls and was located across from the nurse's station. At other times during the day, the resident could ambulate about the units and was kept out of other resident's rooms by mesh screens that were placed across the doors of resident rooms. The DON felt the mesh screens were effective in keeping Resident # 2 out of other resident rooms. The DON added that Resident #2 was toileted every two hours but admitted that there were times when she was incontinent of urine and feces.

During a walking tour/observation of the facility on 6/18/10 at approximately 9:30 am, two doorway screens were noted to be in place across the doorways of the resident rooms, out of the approximate 15 resident rooms on the hallway where Resident #2 resided.

During an interview on 6/18/10 at approximately 10:30 am a registered nurse (RN #1) stated that Resident #2 wanders into other resident's rooms and takes their personal things. There are mesh screens on the resident's rooms, but they don't always work because she is in pretty good physical condition and she ducks underneath the screens and goes into the resident rooms. If the trays are out in the hall she will pick food off of the trays before and after they have been served to other residents. We try to keep the trays in the nurse's station until they are served and keep her in the TV room, but she has been known to come into the nurse's station and if there was food in there, she would take it. She also took the nourishments off of the trays when they were delivered to the unit between meals. "We keep our food in the back room so she can't get at it."

During an interview on 6/18/10 at approximately 11:00 am a registered nurse (RN #2) stated that Resident #2 did display intrusive, wandering behaviors. She frequently kept her hands down inside her pants; sometimes inside the attends and sometimes outside the attends and there were times when she might have had a soiled attends. She goes into the other resident's rooms and picks up their things and will take their food even while they are eating. The residents don't like her in their rooms and they don't like her touching their things with her dirty hands. There are screens placed across the doors to resident rooms to prevent her from entering, but they are not always effective because she ducks under them and goes into the rooms. RN #2 added that at times, the staff members also forget to put the screens up. Resident #2 can be combative and has slapped another resident at least one time. If the food trays are in the hall on the tray cart, she will put her hands in the food and take food off of other resident's food trays. Now we try to keep her in the TV room when the trays are here on the unit. We always keep food for the staff in the back room, so she does not handle our food.

During an interview on 6/18/10 at approximately 12:15 pm CNA #1 stated that Resident #2 frequently wanders into other resident rooms and the resident's don't like it. The screens that are on the doors to the resident's rooms do not always work because most of them are short and she goes under the screen and into the rooms. Some of the screens are ripped and hanging off the doors and she pulls them down. She was toileted every two hours but sometimes we don't catch it and she puts her hands down her pants and her hands are dirty.

2. Resident #3
The resident was admitted to the facility on 05/11/09 with diagnoses of COPD, arthritis and diabetes mellitus. The MDS dated 4/09/10 assessed the resident as having intact long and short term memory and independent for decision making ability. The MDS also documented that the resident makes herself understood and understand others.

During an interview on 6/18/10 at approximately 11:30 am Resident #3 stated that Resident #2, "wanders around and comes into my room. She comes underneath the screen because the screen isn't wide enough to stop her. She puts her hands down her pants and her hands are dirty. She comes in here and she touches my stuff with her dirty hands and I don't like that. She comes under the screen and she touches the other ladies here in the room. I'm afraid that she will hurt one of them. I heard that she put a pillow over another resident's face and I'm afraid that she will do that in here. She's up at night and it scares me because my roommates can't defend themselves. I stay awake at night sometimes and I worry about that."

During an interview on 6/18/10 at approximately 12:15 pm CNA #1 stated that Resident #2 frequently wanders into other resident rooms and the resident's don't like it. The screens that are on the doors to the resident's rooms do not always work because most of them are short and she goes under the screen and into the rooms. Some of the screens are ripped and hanging off the doors and she pulls them down. She was toileted every two hours but sometimes we don't catch it and she puts her hands down her pants and her hands are dirty.

3. Resident #4
The resident was admitted to the facility on 12/12/00 with diagnoses of hypothyroidism, arthritis and diabetes mellitus. The MDS dated 4/30/10 assessed the resident as having intact long and short term memory and independent for decision-making ability. The MDS also documented that the resident makes herself understood and understand others.

During an interview on 6/18/10 at approximately 12:00 pm Resident #4 stated that Resident # 2 wanders into her room and she did not like it when the resident came into her room. Resident #4 stated that Resident #2 sometimes has her hands down inside her pants and then comes into her room and touches her things with her dirty hands. When Resident #4 was asked if the screen on her door was helpful keeping Resident #2 out of her room she stated," It doesn't really seem to help because she goes underneath the screen and comes right in."

During an interview on 6/18/10 at approximately 12:15 pm a Certified Nurse Aide (CNA #1) stated that Resident #2 frequently wandered into other resident rooms and the resident's don't like it. The screens that were on the doors to the resident's rooms do not always work because most of them are short and she goes under the screen and into the rooms. Some of the screens are ripped and hanging off the doors and she pulls them down. She was toileted every two hours but sometimes we don't catch it and she puts her hands down her pants and her hands are dirty.

10NYCRR 415.11 (c)(1)

F242 483.15(b): SELF-DETERMINATION - RESIDENT MAKES CHOICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: September 15, 2010

The resident has the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; interact with members of the community both inside and outside the facility; and make choices about aspects of his or her life in the facility that are significant to the resident.

Citation date: August 2, 2010

Based on observations and staff and resident interviews, during a complaint investigation (Case #NY00087041), it was determined that the facility did not ensure the right to self-determination for 1 (Resident #1) of 4 residents reviewed. Specifically, the facility refused to allow the resident to store half-gallons (no more than two at a time) of ice cream in the facility's freezer compartments. This resulted in no actual harm with potential for more than minimal harm that was not immediate jeopardy. This was evidenced by the following;

Resident #1
The resident was admitted to the facility on 10/26/09 with diagnoses of de-conditioning, lower extremity lymphedema and depression. The Minimum Data Set dated 4/16/10 assessed the resident to have intact long and short term memory and independent with decision making skills.

During an interview on 6/18/10 at approximately 10:30 am, Resident #1 stated that she had been at the facility for more than six months and that she wished she could have ice cream brought to her in half-gallon containers and stored in the facility's freezer. Resident #1 had spoken to the social worker and was told that the facility's kitchen supervisor had refused to allow the storage of the resident's personal ice cream, because there was not adequate room for storage of resident food items and that the state of New York did not allow this because the facility could not ensure that the ice cream had not been thawed and then re-frozen. Resident #1 stated that she understood that she could not place a large number of containers of ice cream in the freezer, but stated she was asking to keep "maybe just two" at a time. The resident stated, her daughter had agreed to purchase the ice cream at the local grocery store when she came to visit and bring the ice cream directly to the facility from the store and have it placed in the facility freezer. Resident #1 stated, "I don't have much to enjoy here, but I truly would enjoy some good ice cream once in a while. The ice cream they serve here tastes like plastic."

During an interview on 6/18/10 at approximately 12:00 noon, the facility social worker stated that Resident #1 had made several requests of her while at the facility and that one of them was to store half gallons of ice cream in the facility freezer, so that it could be available when the resident chose to have a bowl. The social worker stated that the facility kitchen supervisor had reported that they (the facility) could not store ice cream for the resident, because they did not have adequate storage space and the facility could not ensure that the ice cream had not thawed and been refrozen before it was given to the resident.

During an interview on 6/18/10 at approximately 12:30 pm, the Director of Nursing stated that the facility was unable to accommodate the resident's wish to store half gallons of ice cream, because they did not have adequate space to store ice cream for the number of residents that might possibly make the same request. Additionally, the facility could not ensure that the ice cream would be maintained at the proper temperature during transport from the store to the facility (a distance of three miles and eleven minutes driving time). When asked if the facility staff could stop and purchase the ice cream if they were out near the store on facility business, the DON stated that staff, "rarely went to that side of town." In a follow-up interview on 7/20/10 the DON stated, there was also the concern that the resident had gained sixty-plus pounds over the last 9 months and that ice cream was probably not a healthy choice for the resident.

10NYCRR 415.5(b)(1-3)