Mcauley Manor at Mercycare

Based on observations, record reviews, and resident and staff interviews, it was determined that facility staff were not providing cares in a manner to prevent the development and transmission of disease and infection. In three of four observations of incontinence care, staff did not use proper technique or change gloves and wash hands appropriately (Residents #3, #5, and #9). In one of one observation of glucometer use, staff did not clean the glucometer appropriately. During observations in dining rooms in three of three residential units, facility staff did not follow appropriate infection control techniques and procedures. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by, but not limited to, the following:

1. Resident #5 was admitted with diagnoses that include Alzheimer's dementia, severe arthritis, and pressure ulcers. The 10/9/10 Minimum Data Set (MDS) Assessment revealed that the resident is incontinent of bowel and bladder and requires extensive assist for personal hygiene.

During observation of care on 1/11/11 at 10:40 a.m., the Certified Nursing Assistant (CNA) donned gloves and removed the resident's brief that was soiled with stool. The CNA cleansed the resident's perineal region wiping front to back several times with the same washcloth without folding it to a clean area with each wipe. The soiled washcloths were then placed on the floor. Wearing the same gloves, the CNA applied a new brief, dressed the resident, and applied the Hoyer lift sling before removing the soiled gloves and washing her hands.

When interviewed on 1/12/11 at 11:30 a.m., the CNA stated that she placed the soiled linen on the floor because she has been instructed not to put them on the bed. Upon review of the perineal care, the CNA said that she did not realize she had used an improper infection control technique.

In an interview on 1/12/11 at 12:15 p.m., the Registered Nurse (RN) Manager stated that she expects staff to cleanse the perineal area from the front to the back just once before folding the cloth to a clean area or using a clean cloth, and to remove the soiled gloves before touching the residents clothing or Hoyer sling. The RN Manager also stated that they should never place soiled linen directly on the floor.

When interviewed on 1/12/11 at 3:00 p.m., the RN Infection Control Nurse stated that she expects staff to wipe the perineal area front to back just once before changing cloths, and soiled linen should never be placed directly on the floor. She added that she expects staff to remove their gloves and wash their hands immediately after cleansing stool before touching anything.

The facility's policy entitled, "Hand Hygiene," dated 8/25/09, instructs staff to wash hands before and after assisting a resident with personal care and after removing any gloves.

The facility's policy entitled, "Incontinence Care," dated 1989, revealed staff are to remove gloves, wash hands, and reapply clean gloves after removing feces from the resident. It also instructs staff to cleanse the perineal area from front to back.

2. Resident #15 was admitted with diagnoses including diabetes. The 6/15/10 signed physician orders included bedside blood glucose (BG) checks three times daily.

During observation of a medication pass on 1/11/11 at 11:35 a.m., the Licensed Practical Nurse (LPN) went into Resident #15's room with the Accucheck glucometer, set it on his bedside stand, and proceeded to check his BG. When finished, the LPN placed the glucometer on the treatment cart. The LPN proceeded to the medication room, where she started to test Resident #6. At this time, the surveyor intervened to ask the LPN how the glucometer is cleaned between residents. After surveyor intervention, the glucometer was wiped down with 70 percent alcohol before obtaining Resident #6's blood sample. When interviewed at this time, the LPN stated that she cleans the glucometer once a week with alcohol.

When interviewed on 1/12/11 at 3:00 p.m., the RN Infection Control Nurse stated that the facility policy is to clean the glucometer weekly. She also said that she was aware that the Centers for Disease Control recommended cleaning before each resident, but they had not changed the facility policy.

3. Observations of the Dining Rooms include the following:

On the SNF Unit Dining Room:

On 1/10/11 from 11:50 a.m. to 1:00 p.m., two CNAs and one RN touched the resident's hamburger bun with bare hands to cut and/or apply barbeque sauce. On 1/11/11 from 8:00 a.m. to 8:25 a.m., the same staff members peeled the resident's bananas and handed them back to the resident with bare hands.

On the Cranberry Unit Dining Room:

a) On 1/10/11 from 12:32 p.m. to 1:30 p.m., two LPNs and two CNAs were feeding two residents at one time, continually going from one resident to the other, touching the residents, handing them sippy cups, wiping their faces, feeding them, and holding their heads.

b) On 1/11/11 from 7:40 a.m. to 8:22 a.m., one LPN and one CNA were feeding two residents at one time, wiping faces, and touching the residents.

When interviewed on 1/12/11 at 10:45 a.m., the LPN stated that most of the time, they feed two residents and sometimes three at the same time. She stated the staff should wash their hands in between residents.

During an interview on 1/12/11 at 10:50 a.m., the CNA stated there are a lot of residents who need to be fed, so they feed them two at a time. She stated they do not wash hands between the two residents, but if they touched the residents or their clothing they should wash their hands before touching another resident.

When interviewed on 1/13/11 at 9:00 a.m., the RN Manager stated she expects the staff to feed two residents at a time but not to touch the resident. If a resident needs a lot of physical assistance, they should be fed by one staff.

SNF 2 Dining Room:

On 1/11/11 between 8:20 a.m. - 9:10 a.m., a plastic wash basin was placed on the counter top next to the sink and filled with tap water. A pile of dry washcloths was set next to the wash basin. Five of the seven staff assisting residents with their meals and feeding residents used their bare, unwashed hands to take a washcloth off the pile, dip it into the one basin, ring the washcloth out, then use it to clean a residents face and hands once the resident was done with their meal. This continued for 9 residents of the 21 residents seated at the dining tables, until the RN Manager intervened at 9:07 a.m., dumped the basin of water, talked to the staff, then brought in disposable washcloths.

On 1/11/11 at 12:55 p.m., one CNA was interviewed on this practice and said that using the basin in this way was routinely done at every meal.

When interviewed on 1/11/11 at 1:25 p.m., the RN Manager stated that the basin was being used on a routine basis. The RN Manager also said that this practice needs to change to meet infection control standards.

The facility's policy entitled, "Hand Hygiene," dated 8/25/09, instructed staff to wash hands before and after assisting a resident with meals.

The facility policy entitled, "Standard Precautions," dated 9/1/09, instructs staff to perform hand hygiene before and after direct resident contact.

[10 NYCRR 415.19(b)(4)]

Based on observations, staff interviews, and review of medication literature, it was determined that the facility did not provide for the safe and secure storage of medications on two of two residential units. The issues involved controlled substances (narcotics) stored in nonsecured boxes in unlocked refrigerators on the SNF 1 and Cranberry Lane residential units and medications left unsupervised for an extended period of time on the Cranberry Lane residential unit. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

During review of the medication rooms on the SNF 1 unit on 1/10/11 at 10:00 a.m. and on the Cranberry Lane unit on 1/11/11 at 9:25 a.m., the unlocked refrigerators each held a locked metal box containing multiple 2 millimeter size injectable units of Ativan (medication for anxiety). These boxes were not secured and could easily be removed from the refrigerator and/or medication room.

When interviewed on 1/11/11 at 1:00 p.m., the SNF 1 Registered Nurse Manager (RNM) stated that medications have always been stored this way. The box is considered the first lock, and the medication room door is the second lock. When asked if it would be possible to slip the box under a coat and walk out with it she replied, "Yes."

In an interview on 1/12/11 at 9:30 a.m., the pharmacist stated that the narcotics had been moved to the Pyxis system. He reported that the facility had never had medications taken from the medication refrigerators. The pharmacist also said that he considers the Pyxis system as the first lock, and the medication room door as the second lock.

During observations on 1/11/11 at 12:10 p.m., the medication cart was observed in the hallway on the Cranberry Lane residential unit. Two pills in a medication cup and two bags of intravenous (IV) medications were sitting on top of the unsupervised cart. Between 12:10 p.m. and 12:37 p.m., 16 people (13 employees, two visitors and one resident) passed by this unsupervised cart. The RN returned to the medication cart at 12:37p.m. When interviewed at that time, the RN stated that the medications in the cup were Flexeril (muscle relaxant) and Seroquel (antipsychotic). She stated that she poured the medications at 12:00 noon, then went to get a Tylenol with codeine that a resident had requested, and then called for an IV pump. She also stated that the IV bags were Vancomycin and Tobramycin, both antibiotics, and that she placed them on top of the medication cart to warm up prior to administration. The RN said she usually leaves the IV bags on the cart to warm up but probably should not.

In an interview on 1/12/11 at 12:20 p.m., the RN Manager revealed that nurses should keep all medications locked in unsupervised medication carts, and IV medications can be locked in the medication room to warm.

Review of 1/11/10 facility policy entitled, "Storage of Medications," revealed that Schedule II through V medications are stored in the Pyxis system.

[10 NYCRR 415.18(d)]

Based on record review and staff interviews, it was determined that for ten of ten residents reviewed for medication administration, the facility did not ensure that the licensed pharmacist reviewed the drug regimen monthly. All ten medical records lacked or had undated monthly medication reviews. This affected Residents #1, #3, #5, #6, #7, #9, #11, #12, #17, and #18, resulting in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

1. Resident #18 has diagnoses including rheumatoid arthritis and diabetes. Review of the electronic medical record revealed a lack of monthly medication regimen reviews (MRR) from December 2009 through 3/7/10. The medical record included an undated MRR signed by the Director of Nursing (DON) that she dated 11/26/10.

2. Resident #9 has diagnoses including chronic respiratory failure and is ventilator dependent. The electronic medical record included two undated MRRs that were printed on 10/4/10 and 11/16/10. There is no documented evidence of MRRs from December 2009 until 3/22/10.

3. Resident #7 has diagnosis including respiratory failure and is ventilator dependent. Review of the electronic medical record included an undated review signed by the DON on 11/26/10. There is no documented evidence of MRRs from December 2009 until 4/21/10.

Interviews completed on 1/12/11 include the following:

a) At 12:30 p.m., by telephone, the hospital pharmacist said that he completed MRRs after the last pharmacy consultant left on short notice until the position was filled. He said that he did not have immediate access to the electronic record, and he did not make copies of the MRRs that were completed on paper.

b) At 9:20 a.m. and 12:35 p.m., the Registered Nurse/Nurse Manager said that the previous pharmacist left about a year and a half ago, and the new pharmacist has been at the facility about six months.

c) At 12:40 p.m., by telephone, the current pharmacy consultant reported that she started in August 2010 and has remote access to the electronic medical record. When asked about the dates on the reviews, she said that the day should print on the report (MRR: date completed) and then checked her computer settings. She added that the date box had not been checked so she corrected the problem in her computer so dates would print.

During an interview on 1/13/11 at 9:40 a.m., the DON said that the hospital pharmacist was completing the monthly medication reviews but had not kept copies, and the facility has not located these reviews. The DON added that she had not noticed that the dates were missing on some of the MRRs.

The facility's policy entitled, "Consultant Pharmacist Services Provider Requirements," dated 8/1/07, included that a pharmacist will review each resident's medication regimen at least monthly and document the findings in the resident's medical record.

[10 NYCRR 415.18(c)(1)]

Based on record review and staff interview, it was determined that for one of seven employee files reviewed for the Criminal History Record Check (CHRC), the facility did not perform the required CHRC. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy and is isolated. This is evidenced by the following:

On 1/12/11 from 1:10 p.m. to 1:30 p.m., seven employee files were provided by the Human Resources Generalist (HRG) and were reviewed by the surveyor for CHRC documentation. For one of the seven files reviewed, there was no documentation of a CHRC where required. The employee was hired on 5/18/09 as a Food Service Aide and it was confirmed by the HRG that no CHRC had been conducted on this individual. When interviewed at approximately 1:40 p.m., the Nutrition Manager stated that the food service workers primarily stay in the kitchen but will also bring meal carts to the units.

All non-licensed employees that have access to resident living quarters, including dietary aides, must have a CHRC.

Based on observation, and staff and resident interviews, it was determined that for 1 of 24 residents reviewed for dignity, facility staff did not provide care in a manner that enhanced a resident's dignity. The issue involved Resident #24, whose blood was drawn in view of other residents. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #24 has diagnoses including dementia.

During an observation on 1/12/11 at 8:00 a.m., the contract phlebotomist and the Registered Nurse (RN) drew a blood sample from Resident #24, who was located behind the nurses' station. This could be seen by eight residents who were eating their breakfast approximately 10 feet away. At this time, the resident was verbally complaining about the procedure. When asked, three of the eight residents present said they saw the resident having her blood drawn and heard her complaining.

Interviews completed on 1/12/11 include the following:

a) At 8:15 a.m., the RN revealed that blood draws are typically done behind the nurses' station. The RN stated that the blood draw should have been done behind closed doors, not in front of other residents.

b) At 8:45 a.m., the Nurse Manager said that blood draws are done on residents behind the nurses' station, but today, with residents eating breakfast near the nurses' station, it was not a good idea.

c) At 9:00 a.m., the contract phlebotomist, by telephone interview, stated that she always does the resident's blood draws on SNF 2 behind the nurses' station.

[10 NYCRR 415.5(a)]

Based on record review and staff interviews, it was determined that for 1 of 23 residents reviewed for professional standards of quality, the facility did not provide services in accordance with professional standards. Specifically, there was no documentation that physician orders were reviewed and signed in a timely manner for Resident #15. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #15 was admitted on 6/6/02 with diagnoses including renal failure on hemodialysis, a below-the-knee amputation, and diabetes. The most recent comprehensive physician orders in the resident's chart were signed by the physician on 6/15/10.

When interviewed on 1/12/11 at 8:30 a.m., the Registered Nurse Manager (RNM) stated that she usually prints the current orders when the physician does rounds, so they can be reviewed and then signed after the resident is examined. The RNM said that Resident #15's orders were missed several times because he is seen by his physician at dialysis and any new single orders are put in the computer. The RNM confirmed there is no documentation that the full orders were reviewed in detail and that this would be corrected immediately.

In an interview on 1/13/11 at 8:00 a.m., the Director of Nursing (DON) stated that physicians visit residents about every 60 days after the initial 90 days and signs that orders were reviewed. Resident #15 is covered by the dialysis physician, who signs orders in one of the two computer systems being used in the facility. The DON said that at this time the 60-day reviews cannot be signed in the computer, so there is no way to know if they were reviewed.

Review of the 11/10/06 facility policy entitled, "Medical Services," revealed that the physician visits his residents at 30-day intervals for the first 90 days after admission and at least every 60 days thereafter, and all orders are updated at the time of the physician visit.

[10 NYCRR 415.11(c)(3)(i)]

Based on observations, staff interviews, and record review, it was determined that the most recent New York State Department of Health Recertification and Abbreviated Survey results, including the Plans of Correction, were not readily accessible to the residents for examination. This affected all alert and oriented residents residing in the facility. This resulted in a pattern of no actual harm with the potential for minimal harm, and is evidenced by, but not limited to, the following:

Observations made on 1/12/11 at 12:55 p.m. on the SNF 1 residential unit revealed that the results of the Abbreviated Survey, dated 8/26/10, and Plan of Correction were not posted. At 1:00 p.m. on the SNF 2 residential unit, the results of the last Recertification Survey, dated 12/10/09, and the Abbreviated Survey, dated 8/26/10, were not posted.

A joint observation completed on 1/12/11 at 1:10 p.m. with the Administrator revealed that the survey results posted for Cranberry Lane and in the hallway outside the administration area did not include the 8/26/10 Abbreviated Survey results. At this time, the Administrator said that she was not aware that the survey results were not posted on SNF 1 and SNF 2 and did not realize that the Plans of Correction should also be posted.

[10 NYCRR 415.3(c)(1)(v)]

Based on document review and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain the emergency generator. The issue was related to a lack of documented weekly inspections of the emergency standby generator. This affected the entire facility, and resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy and is widespread. The findings are:

During a review of facility records on 1/11/11 at 11:00 a.m., there was no documentation to show that the emergency generator is being inspected weekly. An interview with the Maintenance Mechanic at this time revealed the staff are in the generator room weekly but no official inspection is conducted or documented.

The 1999 edition of NFPA 110, Standard for Emergency and Standby Power Systems, requires that weekly inspections, including all appurtenant components, shall be conducted on emergency generators.

Storage batteries, including electrolyte levels, used in connection with generators shall be inspected at intervals of not more than seven days. A written record of the generator inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.5.1, 9.1.3; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 110 1999: 6-4.1, 6.3.6, 6.3.4]

Based on observations conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain means of egress. The issue was related to items stored in an exit stairwell enclosure. This affected one (North) of three exit stairwell enclosures, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

Observation on 1/10/11 at 1:25 p.m. revealed the exit stairwell located on the first floor next to Conference Room #1066 was being used to store the following items: an x-ray machine, a gurney, a mobile computer table, and a 3-shelf mobile rack full of books, magazines, and movies. Usable space within an exit enclosure, including under stairs or any open space within the enclosure, shall not be used for any purpose that has the potential to interfere with egress.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.2.1, 7.2.2.5.3; 10 NYCRR 415.29(a)(2), 711.2(a)(1)]

Based on observations conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain medical gas. The issue was related to the storage of oxygen cylinders in rooms that do not meet the requirements for storage of oxygen. This affected two (Cranberry, SNF 2) of three resident sleeping units, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. Observation on 1/10/11 at 11:00 a.m. revealed the Clean Utility (2021) and Soiled Utility (2022) rooms, located on the second floor were being used to store oxygen. In the clean utility room, there were two E-size tanks stored approximately 3 feet from disposable brief storage, and there were three duplex electrical wall outlets located approximately 1.5 feet above the floor. In the soiled utility room, there was one E-size tank stored approximately 2 feet from a cart full of trash, and there were three duplex electrical wall outlets located approximately 3 feet above the floor.

2. Observation on 1/10/11 at 2:00 p.m. revealed Room #1150 (Cranberry Unit) was being used for the storage of 14 E-size oxygen tanks, and the room had one duplex wall outlet approximately 4 feet above the floor.

3. Observation on 1/10/11 at 2:05 p.m. revealed Room #1148 (Clean Utility - Cranberry Unit) was being used to store three ventilator supply carts, each of which have two full E-size oxygen tanks. The room has one light switch approximately 3.5 feet above the floor, one duplex wall outlet approximately 1.5 feet above the floor, and shelving containing combustible materials located within 5 feet of the oxygen cylinders.

The 1999 edition of NFPA 99, Standard for Health Care Facilities, requires that in oxygen storage rooms, electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 feet) above the floor as a precaution against their physical damage. NFPA 99 also requires oxidizing gases such as oxygen to be separated from combustibles or incompatible materials by no less than 5-feet.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.3.2.4; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 99 1999: 4-3.1.1.2(a)4, 8-3.1.11.2(c)]

Based on observations and document review conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain the fire alarm system. The issues were related to a lack of sensitivity testing for smoke detectors and a room that lacked a smoke detector where required. This affected a fraction of the fire alarm system, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. On 1/11/11 at 10:45 a.m., records pertaining to the fire alarm system were presented to the surveyor for review. The records showed the last sensitivity testing for facility smoke detectors was on 11/20/08. No additional documentation was provided to show that sensitivity testing has been performed since.

2. Observation on 1/11/11 at 11:25 a.m. revealed Room #1043 (SNF 1) contains the facility's main fire alarm panel, and the room is not equipped with a smoke detector. The room is not a normally occupied space and is kept locked unless access is needed.

The 1999 edition of NFPA 72, National Fire Alarm Code, requires sensitivity testing to be performed within one year of installation and every alternate year thereafter. NFPA 72 also requires that in areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.3.4, 9.6.1.4; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 72 1999: 1-5.6, 7-3.2]