Ridge View Manor LLC

Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY00094433) completed on 12/6/10, the facility did not notify a resident's legal representative or an interested family member when there was a significant change in a resident's physical status and the need to alter treatment significantly. One (Resident #1) of three residents reviewed for a change in physical condition had an issue involving the lack of notification of a resident's legal representative or interested family member regarding the development of blistered and/or open areas on the resident's thighs, heel and buttock. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #1 has diagnoses of hypertension, cerebral vascular accident (stroke), deep vein thrombosis, and depression. Review of the Comprehensive Care Plan (CCP) dated 10/19/10 revealed the resident is alert and oriented with modified independence for decision making, is always understood and usually understands. The CCP documented that the resident is incontinent of bowel,has a Foley catheter (tube inserted into the bladder to drain urine) and requires limited to extensive assistance with activities of daily living.

Review of Nurses' Notes dated 10/16/10 through 10/22/10 revealed the resident had blisters on the front of the right thigh and blood filled blisters on the back of the thigh.

Review of "Wound Documentation" sheets revealed the following:

- On 11/8/10, the resident developed a purple, fluid filled blister on the right heel.
- On 11/11/10, the resident had a Stage 2 slit on the crease of the buttock measuring 2.5 centimeters (cm) long by 0.3 cm wide.
- On 11/19/10, the resident developed a Stage 2 open area on the left inner thigh measuring 1.2 cm long by .3 cm wide, an unstageable area on the right inner thigh measuring 0.4 cm and a Stage 2 open area on the right inner gluteal (buttock) measuring 0.5 cm long x 0.5 cm wide.

Review of Physician's Telephone Orders dated 11/7/10 through 11/8/10 revealed treatment orders were obtained for the open and/or blistered areas on the resident's heels, buttock crease and bilateral thighs.

Review of Social Progress Notes, Nurses' Notes and Daily Unit Reports dated 10/16/10 to 11/29/10 revealed no documented evidence that the resident's responsible party was notified regarding the blistered and open areas on the resident's right heel, thighs and buttock.

Interview with the Licensed Practical Nurse (LPN) Unit Manager on 11/29/10 at 1:00 PM confirmed that the responsible party was not notified of the development of the open areas and the blisters on the right heel and thigh.

415.3(e)(2)(ii)(b)(c)

Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY00094433) completed on 12/6/10, the facility did not provide 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. One (Resident #1) of four residents reviewed for quality of care had issues involving lack of a complete and ongoing assessment including measurements of the resident's blistered areas by a Registered Nurse (RN). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #1 has diagnoses including hypertension, cerebral vascular accident (CVA - stroke), deep vein thrombosis (DVT - blood clot in a deep vein), atrial fibrillation (abnormal heart rhythm), urinary tract infection (UTI), depression and anxiety.

Review of the untitled form (Comprehensive Care Plan (CCP)) dated 10/19/10 identified the resident as alert and oriented with modified independence, some difficulty in making decisions in new situations only, always understood and usually understands, and requires a limited to extensive assist with activities of daily living. In addition, the Personal Care Plan (used by certified nurse aides (CNAs)) revealed the resident is incontinent of bowel and has a Foley catheter (plastic tube inserted into the bladder to drain urine).

Review of the facility Admission Nursing Assessment dated 10/2/10 revealed no documented evidence of any skin impairment.

Review of the Braden Scale (risk assessment sheet used to assess the resident's level of risk for development of pressure ulcers) dated 10/2/10 revealed the resident scored 19. A total score between 15 to 18 indicates the resident is at risk for pressure ulcer development.

Review of Nurses Notes dated 10/16/10 through 11/10/10 revealed the following:

- 10/16/10 - the resident had a blister to the right thigh.
- 10/18/10 - blisters on buttocks applied A&D ointment (protective barrier), needs to be assessed.
- 10/19/10 - blisters covered.
- 10/20/10 - revealed that the MD saw the resident for bloody filled blisters on posterior thigh.
- 10/22/10 - blister front and back right thigh.
- 10/23/10 - blisters continue.
- 10/24/10 - blisters starting to open.
- 10/25/10 - blisters persist on thigh and buttock.
- 11/4/10 - treatment buttocks/thighs.
- 11/9/10 - treatment applied to right upper thigh.
- 11/10/10 - right thigh blister improving.

There was no documented evidence of a complete and ongoing assessment, including measurements of the blistered areas by a Registered Nurse (RN) for the above documented dates.

Review of the medical record revealed no evidence that a Wound Documentation form was initiated 10/16/10 through 11/10/10 when the blistered areas were first identified.

During an interview on 11/29/10 at 1:00 PM, the Licensed Practical Nurse (LPN) Unit Manager stated that the resident was transferred from the facility sub acute unit to the Facility Long Term Care Unit on 11/16/10. The LPN stated that she initiated a skin assessment on 11/19/10 and there were no documented measurements prior to that date regarding the open areas on the resident's inner thighs. Further interview with the LPN revealed a Wound Documentation form should be initiated for any type of wound and monitored weekly.

415.12

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 1/14/10.

Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY00093986) completed on 12/6/10, the facility did not ensure that residents are free of any significant medication errors. One (Resident #4) of three residents reviewed for antibiotic therapy had an issue involving a 36 hour delay in administering an antibiotic ordered by the physician. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Review of the medical record Face Sheet revealed Resident #4 was admitted to the facility from the hospital on 10/1/10 at 4:40 PM. Review of the hospital Discharge Summary revealed the resident had diagnoses including history of osteoarthritis, hypertension (HTN), and chronic obstructive pulmonary disease (COPD). In addition, the Discharge Diagnoses included UTI (urinary tract infection) and sepsis resolved.

Review of the Discharge Medications listed on the hospital Discharge Summary dated 10/1/10 revealed a plan for Levaquin (antibiotic) 750 milligrams (mg) daily through 10/1/10. Review of the hospital Medication Administration Record (MAR) dated 10/1/10 through 10/2/10 revealed the Levaquin had been started on 9/29/10 and that the resident was to receive it until 10/3/10 (5 day course of treatment).

Review of Physician's Orders dated 10/1/10, on admission to the facility, revealed an order for Levaquin 750 mg every day (qd) through 10/1/10. Additional Physician's Orders dated 10/2/10 at 12:30 AM revealed an order to continue Levaquin until 10/3/10.

When interviewed on 11/18/10 at 11:00 AM, the Assistant Director of Nursing (ADON) stated the facility uses an outside pharmacy to obtain the resident's prescribed medications. If a medication is needed on an off hour, the facility uses a 24 hour pharmacy to obtain the medication. Review of the outside pharmacy's Proof of Delivery form revealed that a single dose of Levaquin 750 mg for Resident #4 was not delivered to the facility until 10/2/10 at 6:37 PM. During the interview, the ADON called the 24 hour pharmacy, at the request of the surveyor, and learned there was no record of any medication order being filled for Resident #4. Additionally, further interview with the ADON revealed Levaquin 500 mg tablets are available in the Emergency locked box, however none had been used 10/1/10 through 10/3/10.

When interviewed on 11/19/10 at 5:30 PM, the Registered Nurse (RN) Supervisor stated he worked 3:00 PM to 11:00 PM on 10/1/10 and transcribed the admission orders. The RN further stated he referenced the Discharge Medications documented on the Discharge Summary that revealed the Levaquin was to be given daily until 10/1/10 and faxed the orders to the pharmacy after verifying with the Physician.

Review of the Comprehensive Physician's Order Sheet dated 10/2/10 at 12:30 AM revealed RN #4 received an order to continue the Levaquin 750 mg by mouth (po) daily until 10/3/10. Review of the MAR for 10/2/10 revealed the Levaquin was not given on 10/2/10 and that a dose was not given until 10/3/10 at 12:00 PM.

In summary, the resident had a missed dose of the antibiotic and resulting in a 36 hour delay in administering a single dose of an antibiotic.

On 11/19/10 at 3:30 PM, an interview was conducted with RN #3 who worked the 7:00 AM to 3:00 PM shift and the 3:00 PM to 11:00 PM shift on 10/2/10. The RN stated what the practice was to obtain a medication was but stated "no" she could not say it was done in this case. The RN stated that she had probably given the antibiotic but forgot to initial it but was unable to recall where or how she had retrieved the medication. The ADON informed RN #3 that the medication was not available to give at 12:00 PM on 10/2/10, was not delivered to the facility until 6:37 PM on 10/2/10, and that the dose had been accounted for as being dispensed the following day (10/3/10). RN #3 then stated she had probably seen the discontinued Levaquin order that was initially written above the correct order of administration on the MAR but she probably did not follow through because usually it is written on the MAR to "see new order" or "see below".

When interviewed on 11/19/10 at 2:40 PM, the Attending Physician stated that when a resident is admitted from the hospital the nurse calls him for admission orders that are usually referenced from the discharge summary and other documents sent by the hospital. The nurse reads the information to him and he will order accordingly. The Physician stated he had not been informed the resident did not receive a dose of Levaquin on 10/2/10 and he was not informed it was 36 hours after his order that she received the dose. The Physician further stated that an 8 hour time frame would be the longest amount of time a resident should wait for a medication once ordered, if it is a routine order.

415.12(m)(2)

THIS IS A REPEAT DEFICIENCY FROM THE ABBREVIATED SURVEY COMPLETED 5/26/10.

Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY00093986) completed 12/6/10, the services provided or arranged by the facility did not meet professional standards of quality. One (Resident #4) of four residents reviewed for professional standards had issues involving administration of oxygen over time without a physician's order and delay in obtaining a urinalysis, culture and sensitivity ordered by the physician. In addition, there is no documented evidence that the facility policy to inspect the resident's skin weekly was followed. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #4 has diagnoses including urinary tract infection (UTI), hypertension and osteoarthritis. Review of the untitled form (Comprehensive Care Plan) dated 10/12/10 revealed the resident had modified independence with decision making, usually understands and is always understood.

a). Review of a Comprehensive Physician's Order Sheet dated 10/12/10 at 10:10 AM revealed an order to obtain a urine sample for a urinalysis, culture and sensitivity (C&S). Review of the order transcribed onto the Treatment Administration Sheet (TAR) revealed the sample was to be obtained on the 7:00 AM to 3:00 PM shift on 10/12/10. Review of the TAR and Nurses Notes dated 10/12/10 through 10/17/10 revealed no documented evidence that the urinalysis, culture and sensitivity was obtained.

Review of the Collection Log, where specimens being sent to the lab are recorded, from 10/12/10 through 10/18/10 revealed no documented entry the urine sample was obtained as ordered for Resident #4.

During interview on 11/18/10 at 1:00 PM, the RN Nurse Manager stated it did not appear that the urine specimen was obtained or any follow up was done.

When interviewed on 10/19/10 at 10:00 AM, Licensed Practical Nurse (LPN) #2 stated that he did not obtain the urine specimen on 10/12/10 or 10/13/10 and it should have at least been picked up by the following shift. LPN #2 stated he worked the following day and did not follow up on the urine specimen and explained he just assumed it was obtained and not signed as being obtained.

When interviewed on 10/19/10 at 2:40 PM, the Attending Physician stated that he was not notified that the urinalysis and culture and sensitivity had not been obtained on 10/12/10.

During interview with LPN #1, full time 3:00 PM to 11:00 PM shift on 10/19/10 at 4:00 PM it was confirmed that she had worked the 3:00 PM to 11:00 PM shift on 10/12/10, the shift following the order for the urine specimen. The LPN stated she would not have noticed it (the order for u/a and urine C&S) because she only looks at what is marked for the 3:00 PM to 11:00 PM shift. The LPN explained she does not follow up or address anything from the prior shift, whether it is signed off or not unless it is told to her on the shift report. The LPN further stated the need for the specimen was not given on report or she would have obtained it since the resident had a Foley catheter in place.

b). Review of the Admission Nursing Assessment completed on 10/1/10 for Resident #4 revealed the buttocks were reddened with a 1 centimeter (cm) open area to the buttock.

Review of the Physician's Orders dated 10/1/10 revealed an order to apply zinc oxide (protective barrier) topically every day at bedtime to the sacrum (area above the tailbone on right and left buttocks) /buttocks area and to cleanse the area to the left buttock with normal saline (sterile solution of salt and water), pat dry and cover with optifoam (absorbable foam dressing) every 3 days and as needed.

Review of the Wound Documentation sheet dated 10/6/10 completed by the RN Nurse Manager revealed she had staged the open area on the buttock as a MDS (Minimum Data Set) Stage 1 due to the surrounding skin being intact and blanchable.

During interview with RN #2 on 10/18/10 at 4:30 PM she stated that no further tracking on the Wound Documentation form was required due to the area being a Stage 1 but that the skin integrity would be continued to be assessed weekly per policy on the weekly skin check sheets done on each resident's bath day.

Review of the facility policy and procedure entitled Pressure Ulcers - Risk Assessment and Maintenance of Skin Integrity dated 4/23/10 revealed each resident is to be assessed upon admission, quarterly and with a significant change. The nurse is to complete the Braden Scale (risk assessment sheet used to assess the resident's level of risk for development of pressure ulcers) and is responsible for initiating immediate nursing interventions to maintain skin integrity. In addition, the Braden Scale is to be reviewed by an RN (registered professional nurse). Review of the Braden Scale dated 10/1/10 revealed it was completed by the LPN. There was no documented evidence that the Braden Scale was reviewed by an RN. Further review of the same policy, under the section Skin Inspection and Care, revealed the nurse will inspect the resident's skin weekly on bath day and document the condition.

The weekly skin check sheets for Resident #4 were requested on 11/18/10 at 4:45 PM from the ADON and RN #2. On 11/19/10 at 5:00 PM it was revealed by the ADON and two Corporate Quality Assurance representatives that either the weekly skin check sheets were not done or they just could not locate them or any evidence the skin was checked on a weekly basis in accordance with the facility policy and procedure.

c). Review of Nurses Notes dated 10/2/10 through 10/18/10 revealed repeated use of oxygen by the resident. Review of Physician Orders dated 10/2/10 through 10/18/10 revealed no order for oxygen therapy.

Review of the "Oxygen Therapy" facility policy and procedure dated 7/27/10 revealed the routine use of oxygen requires the physician's order for liter flow (amount of oxygen to be administered) and whether to use a cannula (plastic tubing used to deliver oxygen through the nose) or mask.

During an interview on 11/18/10 at 1:30 PM, both the RN Nurse Manager and the ADON stated "no" the resident did not use oxygen. After reviewing the Nurses Notes dated 10/2/10 to 10/18/10 both of the nurses stated they were not aware that the resident was using oxygen and stated a physicians order is needed.

415.11(c)(3)(i)