East Neck Nursing & Rehabilitation Center

Based on observation, record review, and staff and resident interviews during the standard survey, the facility did not accommodate/provide one resident with a call bell that she could physically use in a timely manner, in a sample of thirty residents. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
(Resident #4)

The finding is:

Resident #4 has diagnoses including Marie Tooth Charcot Disease and Hypertension.

During an observation and interviews on 3/4/10 at 8:45 AM Resident # 4 was in bed and was having difficulty eating. The resident attempted to ring the standard call bell but was not able to. The resident's roommate pointed at the resident and stated that "she has difficulty ringing the call bell so I ring my call bell to get staff to assist her." Resident #4 stated that she does have difficulty ringing the bell.

A Comprehensive Care Plan (CCP) dated 11/4/09 documented that the resident had contractures of the right hand and fingers and that she had decreased strength.

The Minimum Data Set (MDS) Assessment dated 1/28/10 documented that the resident's memory was intact and she was independent with making decisions. The MDS also documented that the resident had functional limitation of the right hand and fingers.

There was no documented evidence in the medical record that the resident was evaluated for the use of the call bell.

During an observation on 3/5/10 at 10:00 AM with the Registered Nurse Charge Nurse for Resident #4, the resident attempted to ring the standard call bell. The resident lifted the call bell in her left hand and attempted to push the button down with the contracted index finger of the contracted right hand. After approximately 4 minutes of attempting the resident was able to push the button and stated "I am not sure if that worked." She also stated that she has been having difficulty the past few weeks and has become more weak.

An interview was held on 3/5/10 at 10:00 AM with the RN Charge Nurse who stated "I see she is having difficulty ringing the standard call bell. I will alert Occupational Therapy (OT) to do an evaluation".

An interview was held on 3/5/10 at 2:30 PM with the OT. The OT stated that Resident #4 was admitted with contractures of her right fingers and hand and that she did not evaluate her for the ability to ring the standard call bell.

An interview was held on 3/8/10 at 11:00 AM with the OT. The OT stated that she had evaluated Resident #4 and had ordered a tap call bell. The OT also stated that the tap call bell should be delivered today.

415.5(e)(1)

Based on record review and staff interviews during the standard survey the facility did not ensure that a comprehensive care plan was developed to meet the residents needs. This was noted for one resident (#14) in a total of 30 sampled residents. Specifically, despite documented pattern of resident's sexual activity there was no evidence that a plan was developed to meet the resident's psycho sexual needs. This resulted in no actual harm with a potential for more than minimal harm which is not an immediate jeopardy.

The finding is:

Resident #14 has diagnoses including Poly Neuropathy, Senile Dementia and a history of Colon Cancer.

The Minimum Data Set (MDS) Assessments dated 5/7/09 and 1/12/10 documented short and long term memory problems and a moderately impaired cognition. The MDS dated 1/12/10 documented the resident exhibited persistent anger, verbal and physical abuse, socially inappropriate behavior and mood which could not be easily altered.

Additionally the Nurse's Remark and Observations (NRO) Form documented several incidents of inappropriate sexual behavior. On 10/23/09, the NRO documented "resident began to exhibit sexual behavior",and his roommate became very upset with this behavior and stated, this goes on every night." On 10/26/09 at 6:00AM, the NRO documented that a Certified Nursing Assistant (CNA) observed that the resident had pulled down his brief and was touching himself and his room mate became upset and is requesting a room change. The NRO documented on 10/27/09 that the resident was found in his room touching himself. Additionally on 10/27/09 the NRO documented that Psych medication Seroquel (anti depressant) was adjusted.

An NRO dated 11/23/09 documented that the resident was exhibiting sexual behavior and moaning at night. A subsequent note on the same date documented that the resident exhibited sexual behavior in front of a CNA. On 11/24/09 the NRO documented that Seroquel dose was increased by the Psychiatrist. The NRO's dated 12/5/09 and 1/3/10 documented that the resident continued sexually inappropriate behavior at times. On 2/14/10 the NRO documented that the resident continued to exhibit sexual behavior, moaning and groaning loudly to himself and that this behavior upsets the room mate frequently.

A Comprehensive Care Plan (CCP) for behavior dated 10/25/09 documented behavior problem related with sexual behavior. The target goal documented that the socially inappropriate behavior will decrease to zero times. The interventions documented to observe and redirect the resident, psychological consult as needed, medications as ordered, inform resident of inappropriate behavior. There was no specific plan documented to accommodate the resident's sexual needs including providing him with privacy. Additionally there was no plan documented to ensure the protection of room mate from being exposed to Resident # 14's sexual behaviors.

The CCP for behavior evaluations section documented on 10/25 and 10/28/09 that Psychiatry evaluation and medication adjustment was done. An evaluation dated 1/13/10 documented that the resident continued inappropriate sexual behavior at night. An evaluation documented on 1/15/10 that the resident continued displaying inappropriate/combative/yelling behaviors, seen by Psychiatrist 1/11/10, continue with medications, psychiatry follow up in one month, staff continue to set limits with his behavior.

The resident was seen by the Psychiatrist on 11/10/09,11/24/09,12/25/09,1/11/10.

The Psychiatry consult dated 11/10/09 documented that the resident continued to exhibit sexually inappropriate behavior at times and that the resident denied this behavior. No change in plan was recommended.

The Psychiatry consult dated 11/24/09 documented that the resident has total disregard for privacy issues, and had no capacity to understand social conventions and denied these behaviors. A Seroquel dose increase was recommended.

The Psychiatry consult dated 12/25/09 documented that the resident continued to exhibit sexually inappropriate behavior and recommended additional Seroquel dose increase.

Psychosocial Assessments dated 5/12/09, 1/18/10 and the Social Work Progress notes from 10/28/09 through 1/26/10 were reviewed. There was no documentation addressing the resident's sexual needs and sexual behaviors. There was no plan to protect the privacy and right of resident #14. Additionally there was no plan documented with regards to protection of the room mate's privacy and dignity.

An interview was conducted with the Social Worker (SW) on 3/7/10 at 2:30 PM. The SW stated when the staff see the resident exhibit sexual behavior they ask him to stop. The SW also stated that the Charge Nurse was responsible to develop a CCP for behavior. The SW further stated that she had not discussed the resident's sexual behavior with the resident and had not developed a plan to protect his rights or his privacy.

The unit Charge Registered Nurse (RN) was interviewed on 3/8/10 at 9:00 AM. The RN stated that no specific plan was developed to address the resident's sexual activity and that she did not think about developing a care plan for the residents rights or his privacy.

415.119c)(2)(i-iii)

Based on observation and staff interviews during the standard survey the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease and infection. This was noted for two out of thirty sampled residents (#34) and (#8). Specifically, during a lunch meal observation, a Licensed Practical Nurse (LPN) was observed to touch the shoes of one resident (#35) followed by retrieving a lunch tray and feeding another resident (#34) without washing her hands. Additionally,the facility did not ensure that appropriate infection control procedures were followed for Resident #8. Specifically, during a dressing change observation the nurse contaminated the normal saline/dressings. This resulted in no actual harm with a potential for more than minimal harm which is not an immediate jeopardy.

The findings are:

1) During a lunch meal observation on 3/3/10 at 12:05 PM, the unit LPN was observed to touch the bottom of the left Darco shoe of Resident #35 and then preceded to retrieve the lunch tray for Resident #34 and started feeding Resident #34. The LPN did not wash her hands between touching Resident #35's shoe and obtaining the tray and feeding Resident #34.

The LPN was interviewed on 3/3/10 at 12:45 PM and stated she should have washed her hands after touching Resident #35's shoe.

The Infection Control Nurse was interviewed on 3/5/10 at 11:00 AM and stated that the LPN should have washed her hands between touching Resident #35's shoe and feeding Resident #34.

2) Resident #8 has diagnoses including End Stage Renal Disease with Dialysis, Diabetes Mellitus and Hypertension.

During dressing change observation on 3/4/10 at 8:00 AM, the (LPN) License Practical Nurse removed the cap from the normal saline, open the gauze pack and placed the gauze 4x4 into the opening of the normal saline and then turned the bottle up side down to moisten the gauze 4x4. The LPN repeated this procedure several times to moisten the gauze used to clean the wound.

During interview with the LPN on 3/4/10 at 8:50 AM, she stated she was unaware that touching the gauze 4x4 to the top of the normal saline bottle was a break in the Infection Control technique.

During interview with the Infection Control Coordinator on 3/5/10 at 11:00 AM, she stated that the appropriate technique is to pour the needed amount of saline onto the gauze 4x4.

Review of the facility's policy and procedure for Pressure Ulcer Management date 9/06, documented to use "pour off technique, pour required amount of solution onto 4x4."

415.19(a)(1-3)

Based on record reviews and staff interviews during the standard survey, it was determined the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 30 sampled residents (Resident #25). Specifically, the facility did not ensure that a legal surrogate (designated in accordance with State law to exercise the resident's rights to the extent provided by State law) was provided for Resident #25, who was unable to make decisions. The facility policy was to designate a surrogate when the resident had no family and that when a resident is unable to make their own decisions guardianship proceedings will be initiated. The policy also documented that the most important reason to have a guardianship in place is to expedite medical treatments. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is :

Resident #25 has diagnoses of advanced Dementia, Failure To Thrive, and Depression.

A medical record review revealed that the resident was admitted to the facility on 4/6/05.

A Psychiatric Consultation dated 12/6/09 documented that the resident has a Diagnosis of Dementia with Depression and that the resident does not eat well.

The Significant Change Minimum Data Set (MDS) Assessment dated 1/14/10 documented that the resident had short and long term memory loss and was moderately impaired with making decisions. The MDS also documented that the resident weighed 112 pounds (lbs) and had a weight loss of 5 percent in 30 days and 10 percent in 180 days.

A Weight record Form documented that the resident weights were as follows:

12/20/09 134 pounds.
1/10 112 pounds.
2/10 115 pounds
3/10 110 pounds.

A Psychosocial Assessment dated 1/15/10 documented that the resident had no Advance Directives in place and that the resident did not have family or friends. The Assessment also documented that the resident had a poor appetite.

Social Work (SW) Progress Notes dated 1/19/10 documented that the significant change meeting was held on 1/19/10 due to a significant weight loss and a poor intake and that the resident had no family. The SW note also documented that the resident had a diagnosis of senile Dementia and was unable to benefit from the meeting. The SW note further documented that the Dietitian would like the Physician to evaluate the resident for possible Gastrostomy Tube (GT) placement for alternate means of nutrition and hydration.

A Physicians Order Form dated 1/19/10 documented to obtain a Gastrointestinal (GI) consult for evaluation for a GT.

A GI consultation dated 1/20/10 documented that the resident has poor oral intake, weight loss and a Diagnosis of Dementia. The consultation also documented to consider a GT if indicated and "family consents".

A SW note dated 1/22/10 documented that the resident was admitted to the hospital on 1/21/10 with a diagnosis of Sepsis.

A SW note dated 2/4/10 documented that the resident was re- admitted to the facility from the hospital on 2/3/10. The SW note also documented that the resident continued to have a poor intake and that prior to hospitalization the Physician was considering a Gastrostomy Tube (GT) for nutrition and hydration.

A Physicians Physical Exam Forms from at least 4/2009 through 2/2010 documented that the resident lacks capacity to make health care decisions.

A SW note dated 2/12/10 documented that the resident was admitted to the hospital with a Diagnosis of Sepsis.

A SW note dated 2/24/10 documented that the resident was re admitted to the facility from the hospital and that all the resident's medications except pain medications and an appetite stimulant were discontinued.

A Nutritional Assessment dated 2/25/10 documented that the resident's oral intake had declined and was inadequate over the past few months.

Nurses Notes dated 3/1/10 , 3/2/10 and 3/3/10 documented that the resident had a poor appetite.

A Physicians Interim Order Form (PIOF) dated 3/3/10 documented to obtain a GI consultation for GT insertion for nutrition and hydration.

A PIOF dated 3/4/10 documented to transfer the resident to the hospital for not eating and a Diagnosis of Failure To Thrive.

During an interview with the Director of Social Work on 3/8/10 at 9:50 AM the SW stated that a significant change care plan meeting for weight loss and decline was held on 1/19/10. The SW also stated that the Medical Director spoke with the resident's Physician about GT placement for alternate means of nutrition and hydration. The SW also stated that although the resident did not have capacity to make decisions, no attempts were made to initiate guardianship for the resident.

During an interview with the Medical Director on 3/8/10 at 11:45 AM he stated that he had transferred the resident to the hospital on 3/4/10 because she was not eating/Failure To Thrive. The Medical Director also stated that it was a non emergency transfer, the resident needed to be evaluated. The Medical Director further stated that if a resident had no family he would notify the resident's need for a GT to the Administrator, who would then discuss it with an attorney. In addition the Medical Director stated that he has spoken to the resident's attending Physician and that the attending Physician did not discuss it further with the Administrator.

In summary, the facility did not ensure that a process of designating a surrogate was initiated for a resident with no capacity to make decisions and no family to assume responsibility.

415.3(c)(1)(iii)

Based on record review and staff interviews during the standard survey, the facility did not ensure that the residents maintained acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible. This was noted for one out of 14 residents reviewed for weight in a total of 30 sampled residents. Specifically, Resident #7 's significant weight loss was not addressed by the facility. This resulted in no actual harm with a potential for more than minimal harm.

The finding is:

Resident #7 has diagnoses including Diabetes Mellitus and is status post fracture of medial Malleolus and Fibula.

The August 2009 Monthly Patient Weight Chart (PWC) documented weekly (August 7, 14, 21 and 28, 2009) weights to be between 235-238 pounds( lbs).The September 2009 PWC documented the weekly (September 4, 11, 18 and 25, 2009) weight to be between 218-220 lbs designating a 17-18 lb weight loss.

The resident's medical record from August 2009 through February 2010 including Comprehensive Care Plan, Dietary Progress notes, Nurses Remarks and Observations notes, Physician's Monthly and Progress notes was reviewed. There was no documented evidence of an assessment of this documented significant (September 2009) weight loss of 17-18 lbs.

The Registered Dietitian (RD) was interviewed on 3/4/09 at 9:10 AM and was unable to state why the weight loss had not been assessed.

The unit Charge Registered Nurse (RN) was interviewed on 3/5/10 at 10:00 AM and stated that the resident's weight loss was due to the removal of the Cam Walker brace. A Physician's order dated 8/10/09 discontinued the Cam Walker brace. However, the RN was unable to explain when the documented weekly weights remained stable through August and the resident lost weight in September, 2009.

The Physician's Assistant (PA) who had documented multiple resident assessments in August and September 2009 was interviewed on 3/8/10 at 1:15 PM. The PA stated that she had been unaware of the significant weight change. The PA stated that the Nursing usually informed her of any significant weight changes and she personally checked monthly weights during the monthly assessments.

415.12(i)(1)

Based on observations, record review and staff interviews during the Standard Survey, the facility did not provide a safety device as care planned for and as ordered by a Physician for one resident at a high risk for falls, of eleven residents reviewed for falls in a sample of thirty residents. Specifically, Resident #12's left wheelchair brake extender had not been provided. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy.

The finding is:

Resident #12 has diagnoses including Dementia, Cardio-Vascular Accident with Hemiplegia, Hypertension, and Glaucoma.

The resident's most recent Minimum Data Set (MDS) Assessment dated 12/29/09 documented her Cognitive Skills For Daily Decision Making as Modified Independence, with some difficulty in new situations only, and with a short term memory problem. The MDS Assessment also documented that the resident was ambulatory with extensive assistance (able to perform part of the activity), and that she was mobile in her wheelchair with extensive assistance or able to perform at least part of that activity.

The resident's most current Physician's Orders dated 2/4/10, as well as her previous Physician's Orders of 1/4/10 documented that the resident was to have a left brake extender on her wheelchair.

The resident's most recent Comprehensive Care Plan (CCP) for Falls/Injury was dated 7/13/09, and updated without changes on 9/30/09, 12/23/09, and 1/20/10. The care plan documented that for safety, the intervention of a left wheelchair brake extender be provided by staff.

Resident #12's Fall Risk Assessment dated 7/13/09, 9/3/09, and 12/3/09 (most current) documented the resident as being at a high risk for falls.

The most recent Physical/Occupational Therapy Screening Forms in the resident's medical record as of 3/4/10 (5/30/09, 6/24/09, 8/18/09, and 9/11/09) documented that the resident required a left brake extender when in her wheelchair.

A Transfer And Referral Record form completed on 2/1/10 by the unit Nursing Care Coordinator (NCC, a Registered Nurse or RN) documented that the resident was able to self-propel herself in her wheelchair, and that her mental status was forgetful.

The resident was observed on 3/3/10 at 12:07 PM in the unit dayroom, and on 3/4/10 at 9:45 AM in the unit hallway. At neither time was a left wheelchair brake extender in place.

The NCC identified the day shift Certified Nursing Assistant (CNA) who cared for the resident, and she was interviewed on 3/4/10 at 10:25 AM and at 1:30 PM. The CNA stated that she had been assigned to this resident's care on the day shift since at least 7/09, she had never seen a brake extender on the resident's wheelchair, and she was not aware that such a device was required. She further stated that the resident did have the ability to be independently mobile in her wheelchair for a limited distance.

On 3/4/10 at 10:30 AM the NCC stated that the left brake extender should have been in place on the resident's wheelchair, and that she would phone maintenance to have such a device put in place. On 3/4/10 at 11:00 AM, the NCC reviewed the Resident's CNA Accountability Record & Resident Plan of Care. She stated that there was no documentation of a wheelchair brake extender being needed for this resident on that document, it had been her responsibility to enter the need for that safety device onto that form, and she had failed to do so.

The Director of Rehabilitation (a Physical Therapist) was interviewed on 3/5/10 at 8:00 AM. He stated that it was his current recommendation on a recent Rehabilitation Screen dated 2/25/10, that the resident no longer needed the device. He further stated that even though he had not yet placed that Screen in the resident's clinical record, until the resident's Physician discontinued the current order for the device, it should have been in place on her wheelchair.

The NCC was interviewed again on 3/5/10 at 8:15 AM. She stated the the facility's Medical Director had discontinued the order for the wheelchair left brake extender, and she had picked up that order on 3/4/10 at 11:30 AM. She stated that until that Physician order was given and picked up, the left brake extender should have been in place on the resident's wheelchair.

415.11(c)(3)(ii)

Based on observation, resident and staff interviews, and Facility Policy review during the Standard Survey, the facility did not treat residents in a manner and in an environment that maintained their dignity and respect for their rooms as their home. Specifically, one of thirty sampled residents, Resident #12, was taken by a Nurse into Resident #33's room for a finger stick procedure. This resulted in no actual harm with the potential for minimal harm that was not immediate jeopardy. The citation of Dignity was a repeat deficiency from the previous Standard Survey of 2/13/09.

The finding is:

On 3/4/10 at 10:35 AM, a unit Medication Nurse (a Licensed Practical Nurse or LPN) was observed taking Resident #12 out of Resident #33's room (a double room).

That LPN was interviewed on 3/5/10 at 8:26 AM. She stated that she had taken Resident #12 for a finger stick procedure (a test for blood sugar levels) into Resident #33's room. She stated that there were no residents in Resident #33's room at the time so there was no problem with what she had done. She stated that it was the first and only time she had ever taken a resident into another resident's room for any care and treatment, and she was not aware of any facility policy addressing such an action.

The Facility's Protocol For Resident Care dated 2/06 was reviewed. It documented that "Staff may utilize the nearest unoccupied or available room when necessary".

The Director of Nursing (DON) was interviewed on 3/5/10 at 11:05 AM. She stated that it was routine Facility Policy that a resident could be taken by staff into any resident's room for treatments such as applying a medication patch to a resident's chest, administering tube feed medications, or for finger sticks. She initially stated that she did not feel that doing so would violate the dignity of the resident(s) who resided in the room being used, as long as no residents were in the room at the time. She further stated that she had interviewed the LPN involved, and the LPN performed the finger stick in Resident #33's room rather than Resident #12's room because she did not want Resident #12 to miss any additional time from the activity she had been in on 3/4/10.

Alert and lucid Resident #33 was interviewed on 3/5/10 at 8:35 AM. She stated that she would be very upset if she ever learned that facility staff used her room to provide care and treatment to any residents other than herself and her roommate.

415.5(a)

Based on observation and staff interview, five of five dayrooms on the nursing units, the 1st floor main dining room and the 3rd floor Tower living area were not provided with single station battery-operated smoke detectors.

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

The findings are:

On 3/3/10 between 8:30am- 3:00pm during the recertification survey, it was observed that the building was not fully sprinklered in that the basement main electrical room, an enclosed closet containing the grease trap in the basement chute room, the beauty parlor on the 3rd floor Tower living area and the 3rd floor Director of Recreation office closet were not provided with sprinkler coverage. Five of five dayrooms on the nursing units, the 1st floor main dining room and the 3rd floor Tower living area were not provided with smoke detectors.

In an interview on 3/3/10 at approximately 10:25am, the Director of Plant Operations stated that he will install the smoke detectors immediately.

711.2(a)(1)