Ridge View Manor LLC

Based on record review and staff interview conducted during a complaint investigation (complaint #NY00086114) during a Partial Extended survey completed 5/25/10, the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Two (Residents #1, 2) of eight residents reviewed for quality of care did not receive necessary care and services. Resident #1 had a PEG (percutaneous endoscopic gastrostomy - feeding tube inserted into the stomach through the abdominal wall) tube replaced by a Licensed Practical Nurse (LPN) which was not in accordance with the facility policy and procedure and without evidence of appropriate training and competency. In addition, the LPN inserted the wrong size and the wrong type of tube which was not in accordance with the physician's order. Resident #2 had a PEG tube replaced by a Registered Nurse (RN) without evidence of appropriate training and competency. This resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. Resident #1 experienced actual harm.

The Immediate Jeopardy was removed on 5/24/10 prior to the completion of the survey.

The findings are:

1. Resident #1 was admitted to the facility from the hospital on 4/13/10 for rehabilitation with diagnoses of a cerebral vascular accident (CVA - stroke) with right sided hemiplegia (paralysis on one side of the body), dysphagia (difficulty swallowing), hypertension (high blood pressure), cardiomyopathy (disease of the heart muscle causing decreased function of the heart) and atrial fibrillation (rapid contractions of the top section of the heart). Review of the Minimum Data Set (MDS) dated 4/23/10 revealed the resident has modified independence in cognitive skills, short and long term memory impairment, understands and has unclear speech but is sometimes understood. The 4/23/10 MDS further revealed the resident has a swallowing problem with a feeding tube in place.

The Comprehensive Care Plan (CCP) dated 5/4/10 revealed the resident has a feeding tube/PEG tube that is required as his primary means of nutritional support. CCP approaches include nursing to provide tube feeding/flush per physician order, flush with 30 cubic centimeters (cc) water before and after medications, elevate the HOB (head of bed) 30 to 45 degrees, and check residuals (the amount of feeding formula remaining in the stomach) per protocol. The CCP does not address the care or replacement of the PEG tube.

a). Review of Physician's Orders dated 4/14/10 revealed an order that the resident's PEG tube may be replaced with a "20 F (French - diameter size of a catheter) 10 cc bulb (the size of an inflatable balloon at the end of a catheter; usually filled with a sterile liquid to anchor the catheter)". Review of a Treatment Administration Sheet dated 5/10 revealed the 4/14/10 physician's order was transcribed correctly.

Review of a Nurse's Note written by Licensed Practical Nurse (LPN) #1 dated 5/4/10 at 2:35 PM revealed she was called to the resident's room by a certified nurse aide (CNA) who informed her that the PEG tube was out. LPN #1 documented "resident noted lying in bed with PEG tube not in abd (abdomen) and (the PEG tube) was also lying in bed". The LPN documented that a "#26" Foley catheter (a flexible (usually latex) tube inserted into the bladder to drain urine) was reinserted with slight bleeding at the G Tube site. Review of the package of the #26 Foley catheter used by LPN #1 revealed the size was 26 French 30 cc balloon that the LPN had inserted.

Review of a Nurse's Note identified as an addendum written by the Registered Nurse (RN #1) Unit Manager dated 5/5/10 at 7:00 AM revealed she was summoned to Resident #1's room by the CNAs and the RN Charge Nurse on 5/4/10 at approximately 5:30 PM. The RN Unit Manager documented the resident's stool had a pinkish tinge to it and the stool on the chux (disposable absorbent pad) also had the tinge around it. The resident had pulse (P) of 82 (average 80), a respiratory rate (RR) of 20 (average 20) and a blood pressure (B/P) of 140/78 (normal). The RN Unit Manager documented that a call was already out to the Physician for other issues and she would inform him upon the return call. The same Nurse's Note documented that at approximately 7:00 PM, the RN Unit Manager was called to the resident's room again and the resident had "large amounts of bright red rectal bleeding" with "large amount of loose brown stool" and there was "blood at PEG site" with small bubbles. She then placed a call to the Physician and an order was obtained to send the resident to the ER (emergency room) via ambulance. The RN Unit Manager documented that the resident had a temperature (T) of 100.3 Fahrenheit (F) (normal 98.6), P of 94, RR of 22 and a B/P of 140/70.

Review of an untimed Resident Transfer Form dated 5/4/10 revealed the resident was sent to the ER due to "rectal bleeding copious amounts".

Additional review of the Treatment Administration Sheet (TAR) dated 5/10 revealed no documented evidence that the PEG tube was changed on 5/4/10.

Review of a hospital GI (gastrointestinal) Consultation Results Report done 5/5/10 at 12:16 PM revealed the resident was admitted to the hospital with a new onset of lower GI bleeding and a CT (Cat Scan - computed tomography - an x-ray that rotates to obtain multiple images) of the abdomen done on 5/5/10 at 3:00 AM showed that the (PEG) tube placement was in the transverse colon with the appearance of a fistulous tract (an abnormal pathway between two spaces) from the colon to the stomach. The GI Consultation documented that abdominal x-rays previously done on 4/9/10 revealed proper placement of the original PEG tube within the stomach.

A hospital Fluoroscopy (an imaging technique used to obtain moving images of internal structures) Report dated 5/5/10 at 2:18 PM documented "abnormal PEG tube position" and "the position of the PEG tube within the transverse colon is confirmed".

Review of a hospital ID (Infectious Disease) Service Consultation Results Report dated 5/18/10 revealed that the resident presented to the hospital from the nursing home after pulling out the PEG tube. The Report documented that the resident was stabilized with a blood transfusion and removal of the Foley catheter that was inserted at the nursing home due to the "fact that it had migrated (moved) into the colon".

Review of a hospital Surgical Consultation Results Report dated 5/18/10 revealed the resident had GI bleeding and bleeding from around the PEG tube site. The GI service evaluated the resident and he underwent an Endoscopy (an exam using an instrument to view the inside of a hollow organ) on 5/6/10 and a clipping of a gastric colonic fistula (an abnormal tract between the stomach and the colon) was performed. The resident then developed sepsis (blood infection) and was seen by ID (Infectious Disease) service who felt the etiology (cause) of the sepsis was abdominal in nature. An exploratory laparotomy (surgical incision into the abdomen to visualize and examine the contents of the abdominal cavity) was done resulting in a colostomy (a surgical procedure in which the colon is connected to the abdominal wall and stool is collected in an external bag).

b). Review of the Green unit Policy and Procedure (P&P) Manual on 5/21/10 at approximately 11:00 AM, in the presence of the Assistant Director of Nursing (ADON) and the RN Unit Manager revealed a P&P entitled "Removal/ Replacement of G (gastrostomy) Tube" dated 6/22/07 and revised 7/17/08. The "procedure" documented nursing staff are to "Assess need for G tube to be replaced and review with the MD. Procedure may be only done by MD/NP or RN". The "procedure" also directed that a Flex-flo G tube or other appropriate G tube is to be used.

During review of the P&P, the ADON and the RN Unit Manager (RN #1) were interviewed and neither were aware of the P&P. The ADON and the RN Unit Manager both stated they were never inserviced or notified of the new policy excluding LPNs from replacing G tubes and neither knew how or who put the policy in the manual.

During an interview on 5/21/10 at approximately 12:15 PM, LPN #5 stated she has worked at the facility for approximately 22 years, was always told LPNs could replace G tubes, and was not aware that they could not. LPN #5 stated that no official training was ever done that she can recall.

During an interview on 5/21/10 at approximately 12:18 PM, LPN #4 who is a "mentor" to new employees stated she was unaware that LPNs could not replace G tubes and was unaware of the 2008 P&P. LPN #4 stated there is no formal training provided for G tube replacement other than observation when a G tube is replaced and confirmed there are no formal skills competency evaluation sheets.

Interview with the RN Unit Manager (RN #1) on 5/21/10 at approximately 12:30 PM revealed she was unaware that LPN #1 had replaced Resident #1's PEG tube until after the fact when the resident started to have the bleeding from the rectum and the G tube site. The RN Unit Manager called the full time day shift RN Supervisor/ Inservice Coordinator (RN #2) and voiced her concerns. The RN Unit Manager explained that she received a call from a PA (Physician's Assistant) from a GI (gastrointestinal) group at the hospital on 5/5/10 and he informed her that the "tip of the tube was in the transverse colon (a part of the colon located across the upper part of the abdominal cavity, next to the stomach)". The RN Unit Manager stated she immediately reported this to the Director of Nursing (DON) and RN #2.

When interviewed on 5/21/10 at approximately 1:45 PM, LPN #1 stated that she did not reference the 5/10 TAR, the 4/14/10 Physician's Orders, or the 7/17/08 P&P and did not notify anyone prior to replacing the G tube. When asked why she inserted a 26 French (a large diameter Foley catheter) with a 30 cc (cubic centimeter) balloon, the LPN stated she "did not know". The LPN stated she was aware that there were Flex-flo G tubes available in the facility. LPN #1 explained that she has been working at the facility for 5 years and that she had previously replaced one other G tube 5 years ago. The LPN stated she has always been told LPNs can replace G tubes from the time she was hired until today. When asked if she had been trained with skills and competency achieved, the LPN stated "no" and that when she was hired she had observed another LPN replacing a G tube. The LPN explained that she was suspended for 3 days on 5/6/10 for not following the physician's order and no one had mentioned the P&P or that LPNs shouldn't be replacing G tubes.

During an interview on 5/21/10 at approximately 2:00 PM, LPN #2 stated that 2 to 3 weeks ago she asked LPN #3 who is a Unit Manager, if LPNs could replace G tubes and she was told yes. LPN #2 stated she has never been trained to replace a G tube and was not aware of any skills competency evaluation.

During an interview on 5/21/10 at approximately 2:40 PM, LPN #3 who has been the Unit Manager on the Yellow Unit for approximately 4 to 5 years, stated she was not aware until today that LPNs could not replace G tubes. Review of the Yellow Unit P&P manual revealed the "Removal/Replacement of G Tube" P&P dated 7/17/08 was in the manual. LPN #3 stated she did not know who put it in the manual, how it got in there and was never informed of it.

During an interview with the Administrator on 5/21/10 at approximately 1:20 PM, a copy of skills competencies' of all professional and licensed nursing staff was requested. RN #2 (Inservice Coordinator) was present during the interview and informed the Administrator that there is no documented evidence of nursing staff competencies. The Administrator was asked how he was made aware of new policy implementation and revisions to existing P&Ps and the Administrator stated he would be told by the DON if the P&P pertained to nursing. The Administrator stated he is made aware of all staff disciplines and suspensions because he signs off on them. When asked about the "suspension" of LPN #1 and the reason for it, he replied he had "no recollection" but "may have" been informed.

When interviewed on 5/21/10 at approximately 2:15 PM, the RN Inservice Coordinator (RN #2) who issued the verbal 3 day suspension to LPN #1 after reviewing with the DON, stated that there was no written documentation regarding the occurrence and the suspension. RN #2 stated she was not aware of the facility P&P that LPNs are not to replace G tubes until today, when it was brought to her attention by the surveyor. RN #2 stated that the suspension was solely based on the physician's order not being followed. RN #2, who is the Inservice Coordinator, confirmed there is no documented evidence that nursing skill competencies are completed on licensed nurses and no evidence that there is a system in place to inservice employees when new policies are implemented or revised.

During an interview on 5/21/10 at approximately 3:00 PM, the ADON confirmed that the suspension was based on LPN #1's failure to follow the physician's order and he was not aware that anyone knew that the current P&P was not followed. The ADON stated "No", he was not aware of the specific policy for Removal/Replacement of G tubes and the revision in 2008 when he was the RN Unit Manager on the Green unit.

During an interview on 5/21/10 at 5:10 PM, LPN #9 she stated she has worked at the facility for approximately 2 years. LPN #9 stated she has never replaced a G tube and that "yes" LPNs can. When asked if she ever had a skills competency evaluation, LPN #9 replied "not that she can remember" and stated that "no" she never received actual training in replacement of G tubes. The P&P was reviewed with LPN #9 and she stated she was "not aware" that LPNs could not replace G tubes.

During an interview on 5/21/10 at 5:20 PM, LPN #6 stated she never received formal training on the replacement of G tubes, was never inserviced regarding the G tube replacement P&P and was not aware of any skills competency evaluations.

When interviewed on 5/22/10 at 5:00 PM, LPN #7 stated she was never trained in the replacement of G tubes was not aware of any skills competency evaluations and was just told that "we were to do it". LPN #7 stated she last replaced a G tube on a resident about 8 months ago and was unaware that a policy revision had occurred in 2008 until today when she reported to work.

During an interview on 5/22/10 at 5:30 PM, LPN #8 stated she replaced a G tube about one year ago and that another LPN showed her on one occasion before that. LPN #8 stated that she did not receive any formal training and she was not aware of skills competencies being done or of the facility P&P.

When interviewed on 5/24/10 at 1:00 PM, the DON stated that LPN #1 was disciplined for not following the physician's order. The P&P was not addressed because she (the DON) was not aware of it. The DON explained that she has been the DON since 2006 and she did not know how or when the revised P&P was put into the facility P&P manuals. The P&P in the facility manuals is the same P&P that is available on the corporate intranet (computer site), that the Administrator printed on 5/21/10. During the interview, the DON was asked how the facility ensures that staff are made aware of current, new and revised policies, and for documented evidence that the facility RNs and LPNs received education, training and skills competency evaluations. The DON stated that evidence of the facility's system to train staff and evaluate skill competencies would be at the corporate office. On 5/24/10 at 4:00 PM the DON stated there was no documentation of skill competency evaluations for nursing staff and no documented evidence that any of the nurses received training on the replacement of G tubes.

Nine of nine LPNs, three of three RNs, the ADON and the DON were not aware of the facility P&P regarding Removal/Replacement of G tube that was revised in 2008 and there was no documented evidence that competency evaluations were done to ensure nursing staff were trained to perform the procedure.

2. Resident #2 was readmitted to the facility on 9/5/09 with diagnoses of dysphagia (difficulty swallowing) with a gastrostomy tube (G Tube - feeding tube inserted into the stomach) and dementia.

The Comprehensive Care Plan (CCP) dated 3/11/10 documented that the resident has a feeding tube/PEG tube that is required due to dysphagia. CCP approaches are for nursing to provide tube feeding/flush per physician order, flush with 30 cc water before and after medications, elevate the HOB (head of bed) 30 to 45 degrees, and check residuals per protocol. The CCP does not address the care or replacement of the PEG tube.

Review of a Nurse's Note dated 1/4/09 at 6:00 AM revealed the resident pulled out his G tube and a 20 Fr/15 cc G tube was replaced per physicians order by RN #3.

Interview with the DON on 5/24/10 at 4:00 PM, revealed there was no documented evidence that RN #3 was trained to replace a G tube or that a skill competency evaluation was done to determine her proficiency.

3. REMOVAL OF IMMEDIATE JEOPARDY.

Review of a letter signed by the Administrator dated 5/24/10 revealed the following actions were taken to remove the Immediate Jeopardy situation in the facility involving the replacement/reinsertion of G tubes. The Immediate Jeopardy was removed on 5/24/10 prior to the exit conference.

a). The facility identified all current residents with a G Tube. There were three residents who had a G Tube prescribed and they were intact.

b). The facility identified 15 RNs and 18 LPNs who needed training on the current policy.

c). The facility distributed the current policy to 12 of 15 RNs and 16 of 18 LPNs and had them sign for it. Two RNs were on vacation and one on disability. One LPN is on vacation and one is unavailable by phone. All will sign for the policy before reporting to work.

d). On 5/21/10, 12 of 15 RNs were verbally instructed that until they could demonstrate and re-demonstrate competency on the proper insertion of a G Tube, they needed to send a resident needing G Tube insertion to the emergency room (ER). No resident needed to be sent to the ER for this procedure.

e). On 5/21/10, the facility began to verbally instruct all LPNs that they cannot insert a G Tube and written notification was provided to them. The LPNs signed that they received this memo.

f). All nurses on duty on 5/21/10 immediately received a copy of the memo; all other nurses were notified by the Supervisor of the memo and policy prior to reporting to work over the weekend.

g). Competency reviews for RNs were conducted starting on 5/24/10 at 8:00 AM. The training was first conducted by the Corporate QA RN, who was trained in this procedure as a nursing instructor. The QA RN immediately inserviced the ADON, Day Supervisor and the Sub Acute Unit Nurse Manager so they will be able to train other RNs.

Interview with three RNs and five LPNs on 5/24/10, between the hours of 9:00 AM and 6:00 PM confirmed that the nurses were all aware of the current policy for G Tube replacement.

h). A protocol was put into place whereby an inservice on G Tube insertion will be held on a semi-annual basis and include a required re-demonstration of technique.

i). Newly hired RNs and LPNs will be inserviced on the policy and RNs will undergo competency training by a registered professional nurse at the time of orientation and before they are able to perform the procedure.

j). The plan will be monitored by the DON and ADON/Designee by reviewing inservice records and competency training records semi annually. Weekly review of records of residents with G tubes will be reviewed over the next 90 days.

Review of facility inservice records on 5/24/10 verified that 12 of 15 RNs and 16 of 18 LPNs were inserviced regarding the facility's current P&P for G tube replacement.

415.12

Based on record review and staff interviews conducted during a complaint investigation (complaint #NY00086114) during a Partial Extended survey completed 5/25/10, it was determined the facility was not administered in an effective and efficient manner that would enable each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being. Among the deficiencies was one resulting in IMMEDIATE JEOPARDY WITH ACTUAL HARM AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY and represents a lack of systems in assuring that residents' health and safety were maintained. The Administrator failed to ensure that systems were in place to educate nursing staff when new policies and procedures are implemented and/or revised and that clinical skills competencies are conducted to ensure staff proficiency. Specifically, nursing staff were not aware of a policy and procedure for the replacement of gastrostomy tubes that was revised in 2008 and a licensed practical nurse replaced Resident #1's gastrostomy tube using the wrong type and sized tube. This resulted in actual harm for Resident #1.

The Immediate Jeopardy was removed on 5/24/10 prior to the completion of the survey.

The findings are:

1. Interviews conducted with the Administrator on 5/21/10, 5/24/10 and 5/25/10 between the hours of 8:30 AM and 6:00 PM revealed the following:

a). The current facility PEG tube policy entitled "Removal/Replacement of G Tubes", provided by the Administrator on 5/21/10, was last revised 7/17/08. Observation on 5/21/10, between the hours of 10:30 AM and 11:30 AM, revealed the same policy was located in the policy and procedure (P&P) manuals on three of three units in the facility. During interviews conducted from 5/21/10 to 5/24/10, between the hours of 10:00 AM and 4:30 PM, nine of nine Licensed Practical Nurses (LPNs), three of three Registered Nurses (RNs), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated they were not aware of the revised policy that directs only MD/Nurse Practitioners (NPs) and RNs can remove/replace G tubes.

b). During an interview on 5/21/10 at approximately 1:20 PM, the Administrator stated he is not involved with the education of nursing staff; facility staff inservicing; policy and procedure (P&P) development, revision or implementation; and that it was the responsibility of the DON. The Administrator stated he was unaware of any facility policy to ensure that each employee is aware of current P&P that are in place.

c). Interview with the Administrator on 5/21/10 at approximately 1:20 PM, revealed he is usually aware of staff who are disciplined. During the interview it was learned that the Administrator was unaware that LPN #1 had violated the facility P&P regarding the replacement of a gastrostomy tube and that the LPN did not follow the physician's order.

d). During an interview on 5/25/10 at approximately 11:45 AM, the Administrator stated that the facility's Medical Director does not approve new or revised policies and has no involvement with nursing policies and procedures. The Administrator explained that the three DONs from the Corporation's three facilities meet and either develop a new P&P or make a revision, the P&P is sent by email from the Corporate office, and selected staff with computer access privileges are to print them and he believes inservice other staff, however there is no system in place to ensure this. The Administrator stated he "works through" the DON, "I don't approve nursing policies".

e). When interviewed on 5/25/10 at approximately 12:30 PM, the Medical Director confirmed that she was not involved with the review of resident care policies and procedures.

f). Review of the facility P&P entitled Removal/Replacement of G Tube, revised 7/17/08, revealed the P&P was approved by the Medical Director. During an interview with the Administrator on 5/25/10 at approximately 12:45 PM, it was learned there was no evidence that the Medical Director had reviewed the 2008 P&P and the Administrator did not know why the P&P documented that. The Administrator was not aware of a system or the process to ensure Medical Director involvement in the review and approval of facility policies.

415.26

Based on record review and staff interviews conducted during a complaint investigation (complaint # NY00086114) during a Partial Extended survey completed 5/25/10, it was determined the governing body failed to ensure the Administrator oversaw the daily management of the facility to attain or maintain the highest practicable physical well-being of each resident. Specifically, the governing body failed to ensure the Administrator was overseen to ensure that facility operated in a manner that ensured each resident received safe, effective care. The governing body failed to ensure that staff were aware, inserviced and followed the Policy and Procedure (P&P) specifically for the "Removal/Replacement of G tube" last revised 7/17/08. The lack of oversight affected two (Residents #1, 2) of eight residents reviewed for G Tubes and resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE to Resident #1 and no actual harm with potential for more than minimal harm to Resident #2.

The Immediate Jeopardy was removed on 5/24/10 prior to the completion of the survey.

The findings include:

1. The governing body failed to ensure the Administrator, appointed by the governing body, developed and implemented policies and procedures as follows:

a). to ensure the facility policy and procedure for Removal/Replacement of G Tube was followed by staff.
b). to ensure staff were aware of the revision to the policy from 7/17/08.
c). to ensure that staff were trained and competent in the implementation of the policy. (refer to F309).

In summary the governing body:

a). failed to identify that the P&P for Removal/Replacement for G tubes was not being followed by their staff, and that nursing staff and management were aware of the P&P to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. (refer to F309)

b). failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial of each resident and failed to operationalize P&P to train employees through competency assessments, on-going development of revisions to P&P and to identify when a P&P was not followed. (refer to F490)

c). failed to ensure the Medical Director provided oversight of resident care policies and procedures, including Removal/Replacement of G tube, and did not ensure that on 5/4/10 Resident #1's G-tube was replaced by qualified staff as of 5/21/10. (refer to F501)

d). failed to ensure the quality assurance committee identified, developed and/or implemented appropriate plans of action to correct a qualified deficiency. On 5/4/10 a Licensed Practical Nurse (LPN) replaced Resident #1's G tube not in accordance with the physician's order and not in accordance with the policy and procedure which resulted in actual harm to Resident #1. The LPN was suspended for not following the physician's order but no staff including the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Medical Director designee were aware the policy was not implemented and was not addressed at the 5/18/10 QA committee meeting.

415.26(b)(3)

Based on record review, policy review, and staff interview conducted during a complaint investigation (complaint #NY00086114) during a Partial Extended survey completed 5/25/10, the Medical Director did not ensure the implementation of resident care policies, and the coordination of medical care in the facility. Specifically the Medical Director did not oversee the development and provide oversight of all resident care policies and procedures (P&P) including Removal/Replacement of G Tubes. This affected two (Residents #1, 2) of eight residents reviewed for G tubes and was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. The facility policy entitled "Removal/ Replacement of G (Gastrostomy) Tube" submitted by the Administrator on 5/21/10 was last revised 7/17/08 and was generated and printed off the computer database. The same policy was on three of three units in the policy and procedure binders. However interview with nine of nine Licensed Practical Nurses (LPNs), three of three Registered Nurses (RNs), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed they were not aware of this revised policy that directs only MD/NP and RNs can remove/replace G tubes.

a). On 5/25/10 at approximately 11:45 AM during an interview with the Administrator, it was revealed that the facility does not have the Medical Director approve new or revised policies and that she has no involvement with nursing policies and procedures. After the three DONs from each nursing home meet and either develop a new P&P or make a revision, it is usually uploaded, sent by email, and those staff with computer access privilege are to go through and print them and he believes in-service, however there is no system in place to ensure this. The Administrator further stated he "works through" the DON "I don't approve nursing policies".

b). On 5/25/10 at approximately 12:30 PM during an interviewi with the Medical Director, she stated she was not involved with the review of resident care policies and procedures and stated "no" she has had no input into the Removal/Replacement of G (Gastrostomy) Tube P&P, or others and she is not aware of reviewing or signing off on any P&P. The Medical Director was not aware that the P&P documented they had been approved by the Medical Director.

c). On 5/25/10 at approximately 12:45 PM following the telephone interview with the Medical Director, it was revealed that even though the Removal/Replacement of G (Gastrostomy) Tube P&P specifies it was approved by the Medical Director, the Administrator has no evidence that they are and does not know why the P&Ps reflect approval by the Medical Director. The Administrator lacked any knowledge of a system or the process for Medical Director approval of resident care policies and procedures.

In summary, the Medical Director did not oversee the development and provide the oversight of resident care policies and procedures, including Removal/Replacement of G-tube, and did not ensure that on 5/4/10, Resident #1's G-tube was replaced by qualified staff.

415.15(a)(1)

Based on record reviews, policy reviews, and staff interviews conducted during a complaint investigation (complaint #NY00086114) during a Partial Extended survey completed 5/25/10, it was determined the Quality Assurance (QA) Committee did not identify or implement appropriate plans of action to address a policy and procedure (P&P) not being followed, ensure staff were aware of the P&P, and that the P&P was approved by the Medical Director. This affected two (Residents #1, 2) of eight residents reviewed for G tubes and was a pattern with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

The finding is:

1. The QA committee failed to ensure that an occurrence of the facility P&P not being followed was identified and that corrective actions were implemented to correct a qualified deficiency. On 5/4/10 LPN #1 replaced Resident #1 G tube not in accordance with the physician's order and not in accordance with the P&P which resulted in actual harm to Resident #1. The LPN was suspended for not following the physician's order but no staff including the Administrator, DON, ADON, RN #2 (Inservice Coordinator and Supervisor), and the Medical Director designee were aware the P&P was not implemented and the problem was not addressed at the 5/18/10 QA committee meeting.

a). The facility policy and procedure (P&P) entitled "Removal/ Replacement of G Tube" dated 7/17/08 revealed that under the procedure section #1 - "Assess need for G tube to be replaced and review with the MD. Procedure may be only done by MD/NP or RN".

b). During interview on 5/21/10 at approximately 2:15 PM with RN #2, the full time 7:00 AM to 3:00 PM Supervisor and Inservice Coordinator, who issued a verbal 3 day suspension after reviewing the occurrence with the DON, stated there was no written documentation regarding the suspension or occurrence and that it was not known until today (5/21/10) when it was brought to the facility's attention by the surveyor. She further stated that she attends the monthly and quarterly Quality Assurance meetings including the monthly QA meeting that was held 5/18/10, after the occurrence.

c). On 5/25/10 at approximately 12:45 PM following an interview with the Medical Director, it was revealed the Medical Director's designee attended a QA committee meeting on 5/18/10 and was not notified about the failure to correctly implement the "Removal/ Replacement of G Tube" policy and procedure.

d). During interview on 5/24/10 at 1:00 PM with the Director of Nursing (DON) she stated that the discipline given to LPN #1 was for not following the physician's order. The P&P was not addressed because she was not aware of it. She does not know how or when it was put into the facility P&P manuals, but she has been the DON since 2006 and she attended the monthly QA meeting held on 5/18/10, after the occurrence.

e). On 5/21/10 at approximately 1:20 PM during an interview with the Administrator it was also revealed that he was unaware that LPN #1 had not followed the facility P&P in addition to not following the physician's order. The Administrator attends the monthly QA meetings and attended the QA meeting on 5/18/10.

In summary, the Medical Director designee, the Administrator, DON, ADON, full time RN day shift Supervisor/ Inservice Coordinator, in addition to nursing Unit Managers attended the monthly QA meeting held on 5/18/10 and did not identify, develop or implement plans of actions to address the concern after the suspension of the LPN.

415.27(a)(c)(3)(ii)