Livingston Hills Nursing & Rehabilitation Center, LLC

Based on medical record review and staff interviews during a complaint investigation, (Complaint # NY00103071) it was determined that the facility failed to ensure that 12 ( #'s- 1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15) of 29 residents identified to be at risk for unsafe wandering, were adequately supervised; failed to have interventions in place to prevent elopement. The facility failed to adequately assess and care plan for residents identified to be at risk for unsafe wandering; failed to operationalize the policy and procedure related to elopement (pictures, lists, drills and documentation) and failed to adequately investigate and report incidents of resident elopement. Additionally, the facility failed to reassess residents who eloped for interventions to prevent further elopement, and failed to identify system failures related to residents who are at risk for unsafe wandering.

Specifically, two residents (#'s 1 and 5), who were identified as at risk for unsafe wandering and wore wanderguards, left the building on three occasions in May and June. Staff responded inappropriately by either failing to react to the alarm or by first re-setting the alarm and notifying other staff the resident had eloped before attempting to retrieve the resident. In two instances, the residents were retrieved in close proximity to a busy road. No investigation into the elopements was conducted and no interventions were implemented to prevent future elopements. Additionally, there was no evidence that missing persons drills have been conducted; 8 of 29 care cards ( used by the certified nurses aides to provide care) lacked care planning for unsafe wandering; pictures and lists of potential wanderers were not accurate; staff were signing for alarm checks for residents who had been discharged or were no longer considered an elopement risk; the enunciator panel signaled the incorrect door alarming; and staff did not have an understanding of elopement policies. This had the potential to effect all 29 residents with exit seeking behaviors. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident's health and safety. This is evidenced by the following:

The facility's policy and procedure stated that those at risk for wandering are identified by black dots that are placed on the residents' wristbands and spines of the charts. The policy also stated that when an alarm sounds, staff are to call a Missing Person Code and conduct an immediate head count. The facility was not compliant with that policy. Head counts were not being conducted and there are no black dots on either the wristbands or the spines of the charts as indicated in the facility's policy.

The facility failed to ensure that residents identified to be at risk for unsafe wandering, were adequately supervised. Additionally, the facility failed to adequately investigate and report incidents of elopement.

Resident #1
The resident was admitted to the facility with diagnoses of dementia, osteoporosis and asthma. The most recent Minimum Data Set (MDS) dated 5/6/11 assessed the resident to have long and short term memory impairment and moderately impaired cognitive skills for decision-making.

A facility policy titled Missing Resident - Emergency procedure dated 7/09, documented that when a door alarm goes off at the facility, a staff person will be assigned by the charge nurse on the unit where the door alarm was triggered, to go outside and walk around the building, searching for the resident.

An accident/incident report (A/I), provided by the facility indicated that at 7:30 pm on 5/29/11, Resident # 1 was noted outside of the facility near the beauty shop.

A document titled Facility Internal Review Quality System Analysis Assurance Quality/Improvement Process, not dated and signed by the Director of Nursing (DON), documented that a review of the incident (5/29/11 at 7:30 pm) on the facility camera revealed there were two residents noted at the alarmed delayed egress door at the time the resident exited. Staff responded to the alarm and reset the alarm based on seeing a (single) resident at the door, however Resident # 1 had already stepped a few feet outside of the door. The author goes on to document, "Failure Mode Analysis revealed a potential degree of human error on one staff member's part."

During an interview on 6/30/11 at approximately 11:30am a Certified Nursing Assistant #1 (CNA) stated that on 5/29/11 at around 7:30pm she was outside in the facility center courtyard having a cigarette when she looked through a glass corridor and could see Resident # 1 on the other side of the glass corridor, outside of, and walking away from the building. CNA #1 realizing the resident was a wanderer and that it was not safe for the resident to be outside unsupervised, ran into the building to the south unit and yelled to a second CNA (CNA #3) for help to bring Resident #1 back inside. CNA' s # 1 and 3 then ran to the exit door at the end of the corridor, went outside and saw Resident #1 walking down the hill, toward the highway (approximately 15-20 yards from the corner of the building). CNA # 1 stated that when she caught up to the resident, she came along easily with the two CNAs.

During an interview on 7/5/11 at approximately 2:00pm a CNA (CNA # 3) stated that on 5/29/11 she was in a resident's room on south unit when she heard CNA #1 yell to her, saying Resident # 1 was outside and she needed help to bring the resident back inside the building. CNA # 3 ran behind CNA # 1 who exited the building through the door at the end of the corridor and as she stepped outside CNA # 3 saw Resident # 1 headed down the grassy slope toward the highway. When CNA # 1 called to Resident # 1, the resident stopped and turned around and came back toward the two CNAs.

During an interview on 6/29/11 at approximately 2:00pm the DON stated that she had reviewed the videotape of Resident #1's exit from the building on 5/29/11 at 7:30pm and although the camera didn't' show the door and the alarm reset keypad, she could assume from what she could see on the videotape that a member of the nursing staff heard the alarm and went to the door near the beauty salon and saw one resident (Resident #5) and thought that was the resident who had pushed on the door, setting off the alarm. The employee didn't realize that Resident # 1 had already exited through the door and was walking along the outside of the building. The DON stated that the employee should have opened the door and looked outside.

An A/I report, provided by the facility DON, dated 5/30/11 at 3:10 pm, (one day after Resident #1's first unsupervised exit from the building) documented that Resident # 1, "was found attempting to go outside the facility through the front entrance and was "caught" by CNA # 2." A statement attached to the A/I report, written by CNA # 2 documented that CNA # 2 heard the front door alarm and observed Resident # 1 standing outside the building at the front door and brought her back inside.

During an interview on 6/30/11 at 11:30am a CNA (CNA # 2) stated that on 5/30/11 as she was leaving the building at the end of her shift, she neared the lobby of the building and heard an alarm ringing. CNA # 2 realized at the time there was no receptionist on duty in the lobby, at the front door. As CNA # 2 walked into the lobby she saw Resident # 1 outside, trying to get back into the building through the front doors. The doors would not open because the resident had a secure care alarm on her ankle, which was locking up the doors. CNA # 2 reset the alarm, opened the doors, walked out and called to Resident # 1 who was now standing at the bottom of a stairway leading up to the driveway. The resident willingly came back inside the building and CNA # 2 walked the resident down the hall and handed the resident off to the registered nurse supervisor (RNS#1) and explained where she had found her. CNA# 1 stated that a couple of days later she had a conversation with the DON and Assistant-Director of Nursing (ADON) and explained to them that when she found the resident on 5/30/11, that the resident was not trying to go out of the building but that she was actually outside the building and was trying to get back inside.

During an interview on 7/1/11 at approximately 3:30pm the facility DON stated that she had given the DOH her entire investigation into the incident and it consisted of an A/I report (filled out by RNS # 1) and a written statement from CNA # 2. The DON stated that it had been her understanding that Resident # 1 was stopped as she attempted to exit the building and she did not know that the resident had been out of the building and was trying to get back inside. When asked if she had viewed the videotape of the incident, she said she had not. When asked if she had asked for statements from anyone else on duty at the time of the incident other than CNA #2, the DON stated that she had not. The DON stated she didn't feel it was necessary to get additional statements from staff because she felt she had all the information. The DON stated the south unit was not a locked unit and she didn't see the need for further investigation into the Resident # 1's attempt to exit the building. She did not report the elopement to the Department of Health (DOH).

The videotape of the facility exit doorways was reviewed by the DOH investigators and revealed that on 5/30/11 at approximately 2:58 pm, Resident # 1 exited the South Unit unnoticed, behind an employee, through the alarmed double doors at the entrance to the unit. A male employee is then seen walking into view of the camera and appears to enter a code on the key pad (used to deactivate the alarm) next to the alarmed double doors. The male employee does not look outside of the double doors to see if a resident has passed through the doors. Resident # 1 is next observed on the videotape at 2:59 pm, at the front main entrance to the building, where she exits the building through both sets of double doors by following behind a male visitor as he exits the building.

Resident # 5
The resident was admitted with diagnoses of dementia, hypertension and degenerative joint disease. The most recent MDS on 4/18/11 assessed the resident to have long and short term memory impairment and severely impaired cognitive skills for decision making.

An A/I report dated 6/24/11 at 2:00pm documented that Resident # 5 was found in her room at the facility removing the screen. She had apparently thrown her purse out the window and stated that she didn't' want to be there anymore.

A document provided by the facility DON (not dated or signed), who described it as an investigation of events involving the resident's exit from the building revealed that Resident # 5 was found on 6/24/11 standing by a window in her room and had pulled the screen out and thrown her purse out the window, stating she did not want to be there anymore. The resident's medications were adjusted and she was placed on 1:1 monitoring and 15 minute checks.

On 6/26/11 at 8:15 am the door was alarming and Resident # 5 was found outside the building by a CNA. She was redirected back to the unit and again placed on 1:1 supervision and 15 minute checks.

During an interview on 7/1/11 at 10:45 am a CNA (CNA # 4) stated that on 6/26/11 at approximately 8:15 am she was caring for a resident in his room on the south unit at the facility when she heard the delayed egress alarm sounding. She could not immediately respond to the alarm because the resident she was caring for was standing and he was not safe to be left alone. CNA #4 stated she seated the resident and made him safe and then responded to the alarm. When she got to the alarming door, she looked outside and saw Resident #5, who was headed down the hill toward the highway. She first turned and yelled to a nurse down the hall that Resident #5 was outside and then she exited the building and ran down the hill, chasing the resident. She called to Resident # 5 and when the resident turned and saw CNA # 4 coming after her the resident started moving faster. CNA # 4 stated she didn't call her name again because she was afraid the resident would start to run. CNA #4 eventually caught up to the resident on the shoulder of the highway.

During an interview on 6/30/11 at approximately 11:00am LPN #1 stated that on 6/26/11 at around 8:15am she was in room 203 on south unit, passing medications when she heard a door alarm ringing. She left the room and went to the alarm panel in the hallway, where she met RNS #1 who had just walked on the unit. Together they noted that the panel indicated the alarm ringing was the exit door in the "OT " (occupational therapy) room; a room off of the unit and next to the main dining room. RNS #1 headed for the OT room and LPN # 1 stood for a few seconds and as she listened, determined that the alarm was coming from the opposite direction and was actually coming from the door at the end of the south corridor. As she approached the door, she heard CNA #4 call out that Resident # 5 was outside. LPN # 1 followed behind CNA #4 out the door, and saw that Resident # 5 was halfway down the grassy hill and the CNA was chasing her. CNA # 4 caught up to the resident at the edge of the highway.

During an interview on 6/30/11 at approximately 12:30pm Registered Nurse Supervisor ( RNS #1) stated that she was walking onto the South Unit on 6/26/11 at approximately 8:15am, when she heard an alarm ringing. She went to the alarm panel on the wall, near the nurses' station and it indicated that the alarm was ringing on the "OT door." RNS # 1 ran off the unit, to the OT door and when she didn't see anyone around she went outside and walked around the building to make sure that no resident had gotten outside. She did not see Resident # 5 outside because she was on the opposite side of the building.

During an interview on 7/1/11 at approximately 11:00am, a registered nurse unit manager (RNUM) stated that it was her responsibility to assess residents periodically for risk of wandering and elopement. She used the "elopement risk status" form to complete this assessment quarterly or more frequently if necessary. The RNUM placed secure care alarms on residents if it was indicated by the assessment or based on her nursing judgment. She stated secure care alarm placement was also discussed by the interdisciplinary team. The RNUM could not provide specific dates for when each resident had their secure care alarms applied. She stated there was no one specific place to find that information but that it could be in a number of places; in nurses notes, assessment forms, care plans, doctors' orders, treatment sheets, etc. When a secure care alarm was placed on a resident it should be added to the treatment sheet and the treatment nurse should check for placement each shift; and it should be added to the supervisor's book and they checked the alarms each night-shift for function. The resident's name was also placed on a wanderguard list on the unit, along with a picture to identify each resident and these pictures were kept on each unit and at the receptionist desk in the main lobby.

The facility failed to adequately assess and develop a care plan with interventions for residents identified at risk for unsafe wandering, Additionally the facility failed to reassess residents who had eloped for additional interventions to prevent future elopements.

Resident #5
A physician's order dated 8/26/10, instructed the staff to apply a "wanderguard." An "Elopement Risk Assessment," for Resident #5, dated 4/20/11, instructs that if a yes is checked for any starred question on the form, the resident is at immediate risk and a "wanderguard" should be applied. Question # 6 on this form is checked in the "yes" column indicating the resident is at immediate risk and should have a Wander Guard applied.

An A/I report dated 6/24/11 at 2:00pm documented that Resident # 5 was found in her room at the facility removing the screen. She had apparently thrown her purse out the window and stated that she didn't want to be there anymore. A second A/I report and attached statements, documented that on 6/26/11 at approximately 8:15am, Resident # 5 exited the building, unsupervised and was observed walking toward the highway.

The care plan for elopement for Resident # 5 is dated 6/29/11, three days after she exited the building and 10 months after the physician's order was written for a wanderguard. There is no reassessment for elopement after the resident exited the building on 6/26/11. The facility was not able to provide a care plan for unsafe wandering prior to 6/29/11.

Resident # 6
The resident was admitted to the facility with diagnoses of dementia, diabetes mellitus and hypertension. The most recent MDS dated 6/14/11 assessed the resident to have long and short term memory impairment and severely impaired cognitive skills for decision-making.

An A/I report with attached employee statements dated 6/10/11 at 8:00 am, documented that Resident # 6 was returned to the facility by an LPN after she exited the building, unsupervised, setting off the door alarm. There is no RN assessment documented and no RN signature on the document to indicate that an assessment was done. Nurses notes documenting the event are signed by LPN's.

A document provided by the facility, titled "Elopement Risk Assessment," assessing Resident # 6, dated 6/13/11, (three days after the resident exited the building unsupervised) instructed that if a "yes" is checked for any starred question on the form, the resident is at immediate risk and a Wander Guard should be applied. Question # 7 on the form asks, "Does the resident have a history of leaving the facility without needed supervision?" The RN assessing Resident # 6 answered "no" to this question.

The care plan for elopement for Resident # 6 is dated 6/29/11, nineteen days after the resident exited the building. There are no additional interventions added. The facility was not able to provide a care plan for unsafe wandering prior to 6/29/11.

The facility failed to operationalize the policy and procedure related to elopement (pictures, lists, drills and documentation).

During interview on 6/29/11 at approximately 11:30am, the DON stated that the functionality of secure care bracelets and alarmed doors were checked each night by the night shift supervisor and the treatment nurses checked each shift to ensure that secure care bracelets were on each of the appropriate residents. When the facility DON was asked for a copy of the current policy/procedure (P&P) for management of wandering residents, she provided a copy of a P&P dated June 2006. The policy directed staff to apply black dots to resident name bands and the spines of the resident's medical record if they were at risk. During an interview on 7/1/11 at approximately 5:00pm the facility Administrator stated that the policy from June 2006 had been revised and that black dots had been eliminated from the procedure.

The "Wandering Resident" P&P dated 7/07 documented that pictures of residents at risk for elopement will be kept at the receptionist desk, nursing stations, recreation and dietary departments. On 6/29/11 at 5:00pm a list provided to the DOH by the facility indicated that six residents on the east wing had secure care bracelets in place. A review of pictures at the receptionist desk at that time revealed there were four pictures posted for east wing residents. Two of the four residents whose pictures were posted, had been previously discharged, leaving four residents who were at risk without pictures. The list also indicated there were 7 resident's on the north wing with secure care bracelets. Of the seven residents only five had pictures at the receptionist's desk. A list of resident's names taken from the supervisor's secure care binder (used for checking function of wanderguard's at night) indicated there were 15 residents on the south wing with secure care bracelets. Of the fifteen residents on the supervisor's list, ten did not have pictures at the receptionist desk. A review of three lists of names of residents with secure care bracelets, obtained from three different sources (one taken from the wall in the nurse's station on south unit, one taken from the supervisors secure care bracelet binder in the supervisors office and a third received from the evening supervisor, being used as an audit tool revealed multiple inconsistencies with all lists.

The facility failed to identify system failures related to residents who are at risk for unsafe wandering.

During an interview on 6/30/11 at approximately 2:30pm the facility administrator stated that the facility had not conducted a "missing person drill" during the last year.

Resident # 7 During an interview on 6/29/11 at approximately 11:15am, the RNUM stated that she could not recall exactly when Resident #7 had her secure care bracelet discontinued but it was more than "several weeks ago."

A review of the treatment sheet for the month of June 2011 for Resident # 7, revealed that the placement of the resident's secure care bracelet was verified daily on all three shifts, through 6/29/11.

Resident # 8 The resident was admitted to the facility diagnoses of dementia, hypertension and Parkinson's disease. The most recent MDS, dated 4/10/11 assessed the resident to have long and short-term memory impairment and severely impaired cognitive skills for decision-making.

A nurses note dated 6/14/11, no time entered, documented that Resident # 8 is taken outside daily by his son and has not made an attempt to leave the unit or the facility unsupervised and the wander guard was discontinued and removed.

A review of the treatment sheet for Resident # 8, for the month of June 2011, revealed that the placement of the secure care bracelet was verified by nursing personnel on all three shifts from June 14, 2011 through June 17, 2011.

A review of the supervisor's sheet for checking the function of the resident's wanderguard documented that the device was checked every night by a supervisor from 6/14/11 through 6/29/11.

During an interview on 7/5/11 at approximately 4:30pm, RNS #2 stated that each night that she works, she checks the wanderguard alarm functionality of any resident who has a sheet in the supervisor's log book. She recalled that Resident # 8 was one of a couple of residents who would repeatedly remove their wanderguard's and she would replace them when she found them missing. RNS # 2 insisted that if she documented that she had checked Resident # 8's wanderguard for function, then she had actually done it because she would never document something that she had not done. She could not explain why it was documented in the nurse's note that it was removed on 6/14/11 and the function was checked through 6/29/11.

10 NYCRR 415.12(h)(1)(2)

Based on observation, record review and staff interview during a complaint investigation (Complaint # NY00103071) it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Administration failed to ensure that resident's care was provided in a safe, secure and supervised environment for residents at risk for unsafe wandering and elopement. Specifically, the facility's administration failed to ensure that effective systems to maintain residents safety were utilized, failed to ensure residents were supervised to prevent accidents and failed to thoroughly investigate an incident of elopement. This resulted in no actual harm that is Immediate Jeopardy to resident's health and safety. This is evidenced by the following:

Refer to Quality of Care - Accidents, F-323 scope/severity - K

The facility failed to provide adequate supervision for residents who were identified to have dementia, and to be at risk for elopement. Additionally, the facility failed to have an effective system to identify residents who were at risk for elopement and to ensure that electronic monitoring systems were operating effectively.

Refer to Quality Assurance, F-520 scope/severity - K

The facility failed to implement an effective Quality Assurance (QA) program that readily identified deficiencies in the implementation of its policy for wandering/elopement behaviors; failed to ensure that new interventions were initiated after incidents of elopement. Additionally the QA program failed to ensure that incidents of elopement were thoroughly investigated and reported to the State Agency.

During an interview on 6/30/11 at approximately 2:30pm the facility Administrator stated that the facility had not conducted a "missing person drill" during the last year.

During an interview on 7/1/11 at approximately 1:30 pm, the Administrator stated that the facility's QA Program had not looked at unsafe wandering/elopement recently because they had focused on areas that had been the subject of prior deficiencies.

During an interview on 7/1/11 at approximately 4:00 pm, the Administrator stated he was not told of the resident elopements by the Director of Nurses.

10 NYCRR 415.26

Based on medical record review and staff interviews during a complaint investigation (Complaint # NY00103071) it was determined that the facility did not have a quality assurance (QA) program which effectively identified problems and established corrective actions for the management of unsafe wandering/elopement behaviors for twelve of twenty-nine residents reviewed with exit seeking behaviors. Specifically, the QA Program failed to develop a policy on prevention of elopement/unsafe wandering that clearly defined the process for management of residents with exit seeking behavior; failed to ensure residents identified to be at risk for elopement/unsafe wandering were supervised to prevent elopement; failed to ensure that comprehensive care plans that identified individualized needs were developed, actions and/or interventions to prevent/protect residents who were identified to be at risk for elopement/unsafe wandering. This had the potential to effect all 29 residents with exit seeking behaviors. The failure of the QA Program to assure safe outcomes for residents resulted in no actual harm that is Immediate Jeopardy to resident's health and safety. This is evidenced by the following:

The findings were as follows:

Refer to Quality of Care-F 323 scope/severity K

Refer to Administration- F 490 scope/severity K

On 6/29/11 at approximately 11:30am, the facility Director of Nurses (DON) was asked for a copy of any current policy/procedure (P&P) addressing the management of wandering residents, she provided a copy of a P&P dated June 2006, titled "Protocol of Care, Wandering Resident Management Elopement Prevention," a second P&P titled "Missing Resident-Emergency Procedure" dated July 2009 and a third P&P titled "Secure Care Alarm System", dated August 2006.

During an interview on 7/1/11 at approximately 5:00 pm the facility Administrator stated that the policy from June 2006 was not the facility's current policy. He stated the policy had been revised and some procedures had changed. When the DON was again asked on 7/5/11 for a copy of a current P&P, she provided the DOH investigator with a policy revised in June 2007, titled "Wandering Resident Elopement Risk Assessment."

A review of the facility's current policy revealed there is no instruction on monitoring of secure care devices and no procedure to be followed when a secure care alarm or a door alarm sounds.

During an interview on 7/1/11 at approximately 1:30 pm, the Administrator stated that the facility's QA Program had not looked at unsafe wandering/elopement recently because they had focused on areas that had been the subject of prior deficiencies.

10NYCRR 415.27(a-c)

Based on medical record review and staff interviews during a complaint investigation, (Complaint # NY 0010307) it was determined that the facility did not ensure that services being provided met professional standards of quality for two (Residents # 1 and 2) of four residents reviewed. Specifically, the facility did not ensure a Registered Nurse (RN) assessment was completed for Resident # 1 after she was noted to have exited the building, unnoticed and was walking away from the building; and there was no RN assessment for Resident # 2 when the resident was found on the floor in front of her wheelchair after an unobserved fall. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy:

Resident #1
The resident was admitted to the facility on 4/27/11 with diagnoses of dementia, osteoporosis and asthma. The most recent minimum data set (MDS) dated 5/6/11, assessed the resident to have long and short term memory impairment and moderately impaired cognitive skills for decision-making.

An accident/incident report (A/I), provided by the facility indicates that at 7:30pm on 5/29/11, Resident # 1 was noted outside of the facility near the beauty shop. There is no registered nurse signature on the document, indicating a RN assessment was completed.

A nurse's note, dated 5/29/11 at 7:30pm and signed by an licensed practical nurse (LPN), documented that Resident # 1 was found outside the building at approximately 7:30pm. The note also documented that it was unknown how the resident got outside of the building. There is no RN assessment documented and no nurse's note entered by an RN.

During an interview on 7/3/11 at approximately 9:00am, the facility Director of Nurses(DON) stated that there is not always an RN in the building and when there is no RN supervisor and there is an incident with a resident, the LPN's know that they can call any of the RNs if the LPN thinks the resident should be seen by an RN. When the DON was asked if there is an " on-call RN " the DON stated there was no "on-call " list but the LPN's could call any of the RNs on the staff and one of them would come in to see a resident. When the DON was asked if there was any written criteria or a policy to guide LPN's on when to call an RN the DON stated there was not.

Resident # 2
The resident was admitted to the facility on 4/20/11, with diagnoses of hypertension, uncontrolled atrial fibrillation and chronic kidney disease. The most recent MDS for the resident dated 6/14/11 assessed the resident to have long and short term memory impairment and moderately impaired cognitive skills for decision-making.

An A/I report dated 6/19/11 at 5:30pm documents that the resident had an unobserved fall from the wheelchair. There is a signature on the form indicating the name of an RN that provided an assessment and directed staff to move resident. However there is no RN assessment documented on the form.

A review of nurses notes for this date 6/19/11 reveals there is no note written by an RN and no RN assessment has been documented. The note documenting the fall is signed by an LPN and the LPN documented that the resident was yelling for help and was found on the floor in front of her wheelchair and no injuries were noted.

During an interview on 7/3/11 at approximately 9:00am, the facility DON stated that there is not always an RN in the building and when there is no RN supervisor and there is an incident with a resident, the LPN's know that they can call any of the RNs if the LPN thinks the resident should be seen by an RN. When the DON was asked if there is an "on-call RN " the DON stated there was no " on-call " list but the LPN's could call any of the RNs on the staff and one of them would come in to see a resident. hen the DON was asked if there was any written criteria or a policy to guide LPN's on when to call an RN the DON stated there was not.

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

Based on observation and staff interview during immediately jeopardy monitoring, it was determined that the exit discharges to the public way were not free of all impediments for full instant use. NFPA 101 Life Safety Codenone 2000 edition section 7.10.1 states that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Specifically, the 2 of 10 delayed egress doors would not open when tested. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The director of nursing was present for all observations. This is evidenced as follows.

The delayed egress doors were checked for functionality on 07/02/2011. The director of nursing was near each door holding a " Secure Care System " bracelet during each test. At 12:05 pm the delayed egress door in the activities room would not open when tested by leaning on the door panic bar handle with full weight for 90 seconds. At 12:25 pm the delayed egress door in the north dining room would not open when tested by leaning on the door panic bar handle with full weight for 75 seconds.

The director of maintenance stated in an interview conducted on 07/02/2011 at 1:00 pm that the delayed egress doors noted above function when tested last week.

2000 NFPA 101 7.10.1; 1997 NFPA 101 5-1.9; 10 NYCRR 415.29, 711.2(a)(1)