North Shore Univ Hosp Stern Family Center for Extended Care & Rehab

Based on observation and staff interview, the facility did not sure that infection control techniques were followed during 1 of 4 medication pass observations. Specifically, a Licensed Practical Nurse (LPN) medication nurse did not clean the blood pressure cuff or pulse oximeter either before or after using them on Resident #32. Also, the LPN medication nurse popped a medication blister pack with the tip of her pen when retrieving a medication for Resident #32. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The Findings are:

During medication pass observation on 7/24/12 at 8:00 AM, the LPN medication nurse was observed to take the blood pressure and pulse oximeter machine from the hallway and bring them into Resident #32"s room. The nurse took the resident's blood pressure and pulse using the equipment. After she was through using the equipment, the nurse returned the equipment to the hallway. She did not clean the equipment either before or after using the equipment on the resident.

During the same medication pass observation on Resident #32, with the tip of her pen, the LPN medication nurse was observed piercing the blister pack of the drug Enablex, to extract the medication from the blister pack. It was the same pen that the nurse had been using to document on the MARs.

On interview with the LPN medication nurse on 7/24/12 at 9:00 AM, the nurse stated that she is supposed to clean the blood pressure and pulse oximeter equipment after each resident. She also said that she used the tip of her pen to pop the blister pack open because if she pops the blister pack with her hand, sometimes the Enablex disintegrates and then the resident does not want to take it.

415.19(a)(1-3)

Based on observation and staff interviews during the recertification survey the facility did not ensure that the resident environment remained free of accident hazards in that 1) potentially harmful products were found to be in the unlocked bathroom of three resident's bathrooms on the 2 South West Unit and 2) for 1 of 13 residents observed during the medication pass observations, Resident #32 had Fluticasone (Flonase) nasal spray being stored in an unlocked drawer in his room. This resulted in no actual harm with the potential for more than minimal harm.

The findings are:

1) On 7/23/12 between 8:40 AM-9:50 AM the following was noted:

In the bathroom of rooms 225, 226, 227, 228, 229, and 235 there was a shelf/ledge area on the back of the toilet with one container of Sani-Cloth Plus Germicidal Disposable Cloths. Printed on the containers was "for use on equipment ; external use only; when using this product wear disposable protective gloves".

The Material Safety Data Sheet 1/15/05 for Sani-Cloth Plus Germicidal Disposable Cloth documented eye contact-causes moderate eye irritation; inhalation-vapor concentrations are irritating to the eyes and the respiratory tract. First Aide Measures for eye contact, inhalation and/or ingestion -get prompt medical attention.

The 7:00 AM-3:00 PM shift Licensed Practical Nurse/Charge Nurse was interviewed on 6/11/12 at 8:45 AM. She stated that marked for external use only should not be in the unlocked bathroom areas unless the staff is present.

The Registered Nurse Manager 2 South East Unit was interviewed on 7/23/12 at 10:05 AM and she stated that the potentially hazardous items such as the Sani-Cloth Plus Germicidal Disposable Cloth should not be left unsupervised in any resident rooms, or bathrooms and should be locked if there is no staff present in the room.

2) On 7/24/12 at 8:00 AM, the Licensed Practical Nurse (LPN) medication nurse was observed to pour, administer and sign for 13 medications for Resident #32. Upon reconciliation of the medications with the current Medication Administration Record (MAR) and the current Physician's medical orders (7/19/12), it was noted that Fluticasone (Flonase) nasal 50 mcg spray, 1 spray in each nostril twice daily for nasal congestion/allergies, was signed for on 7/24/12 at 9:00 AM, but the medication nurse had not given the resident the nasal spray during the medication observation.

On interview with Resident #32 on 7/24/12 at 9:18 AM, the resident stated that he takes the Flonase (Fluticasone nasal 50 mcg spray) himself everyday. The resident open the drawer of his over bed table and removed the Flonase bottle.

On 7/24/12 at 9:20 AM, during an interview with the LPN medication nurse, she stated that the resident takes the Flonase himself. She then proceeded to go into Resident #32's room and ask him if he took his Flonase that morning. The resident responded that he did. The nurse did not respond when asked why she signed the MAR as if she gave the Flonase to the resident before she validated that he had taken the medication.

During an interview with the Registered Nurse (RN) Unit Manager on 7/25/12 at 9:45 AM, she completed an assessment of the resident on 7/24/12 and determined that the resident was safe for self administration. However, the medication is supposed to be stored in a locked box in the resident's room. The resident refuses to use a locked box because he has difficulty opening the locked box.

415.12(h)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accidents/Incidents (A/I) were thoroughly investigated for 1 of 15 sampled residents reviewed for abuse/neglect/mistreatment. Specifically, Resident #5 was observed to have an ecchymosis to the left upper arm without investigations being completed to determine whether abuse, neglect or mistreatment occurred. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #5 has diagnoses that included deep vein thrombosis (DVT) .

The Initial Skin Assessment dated 7/4/12 lacked documented evidence of an ecchymosis to the left upper arm.

The Minimum Data Set (MDS) Assessment dated 7/20/12 documented the resident's cognition as cognitively intact.

On 7/23/12 at 10:45 AM Resident was observed with an ecchymosis to the left upper arm. Resident #5 was interviewed and stated, "The nurse hit me". The resident later stated, "When I said that the nurse hit me, I was just joking around."

The Interdisciplinary Care Plan for Skin Care dated 7/23/12 documented ecchymosis left upper arm.

The Interdisciplinary Care Plan for DVT dated 7/24/12 documented left upper arm purpura.

Resident #5's Inter-Disciplinary Progress Note dated 7/3-23/12 lacked documented evidence of an ecchymosis to the left upper arm.

The 7:00 AM-3:00 PM Registered Manager was interviewed on 7/23/12 at 3:45 PM. The RN stated that she was not aware that Resident #5 had an ecchymosis to the left upper arm. . The RN further stated that the Certified Nurses Aide is to complete a daily skin check during care on a daily basis and when ever care is given. The RN stated that Resident #5 did not report that anyone on the staff had hit him and that an investigation would be started.

The Attending Medical Doctor (MD) for Resident #5 was interviewed 7/24/12 at 8:30 AM. The MD stated that when he was informed that the resident had an ecchymotic area to the left upper arm on 7/23/12 (time not recalled) he examined the resident. The MD stated that it was his impression that the resident had the ecchymosis to the left upper arm since admission on 7/3/12 to the facility.

The Certified Nurses Aide (C.N.A.) assigned to Resident #5 on 7/23/12 on the 7:00 AM-3:00 PM shift was interviewed on 7/24/12 at 12:40 PM. The C.N.A. stated that the resident had a discolored area on the left arm but she thought that this was present since the resident was admitted to the facility. The C.N.A. told the nurse on the 11:00 PM-7:00 AM shift but did not recall the date. The resident did not state to her that anyone hit him.

An attempt was made to contact the 11:00 PM-7:00 AM shift RN on duty on 7/23/12 but this was not successful.

The Director of Nursing was interviewed on 7/24/12 at 12:40 PM and stated that an investigation was started to rule out abuse, neglect or mistreatment for Resident #5.

The Occurrence Report dated 7/24/12 documented that Resident #5 reported a bluish discoloration to his left upper arm dated 7/24/12 and the investigation was started.

415.4(b)(1)(ii)

Based on observation, record review and resident and staff interviews, the facility did not assess or care plan for self administration of medications for 1 of 13 residents observed during the medication pass observations. Specifically, Resident #32 was observed with a bottle of Fluticasone nasal 50 mcg spray in his over bed tray table drawer. The resident was not assessed or care planned for self administration of medications. This resulted in no actual harm but has the potential for more than minimal harm that is not immediate jeopardy.

The Finding is:

On 7/24/12 at 8:00 AM, the Licensed Pracical Nurse (LPN) medication nurse was observed to pour, administer and sign for 13 medications for Resident #32. Upon reconciliation of the medications with the current Medication Administration Record (MAR) and the current Physician's medical orders (7/19/12), it was noted that Fluticasone (Flonase) nasal 50 mcg spray, 1 spray in each nostril twice daily for nasal congestion/allergies, was signed for on 7/24/12 at 9:00 AM, but the medication nurse had not given the resident the nasal spray during the medication observation.

On interview with Resident #32 on 7/24/12 at 9:18AM, the resident stated that he takes the Flonase (Fluticasone nasal 50 mcg spray) himself everyday. The resident open the drawer of his over bed table and removed the Flonase bottle.

On 7/24/12 at 9:20 AM, during an interview with the LPN medication nurse, she stated that the resident takes the Flonase himself. She then proceeded to go into Resident #32's room and ask him if he took his Flonase that morning. The resident responded that he did. The nurse did not respond when asked why she signed the MAR as if she gave the Flonase to the resident before she validated that he had taken the medication.

During an interview with the Registered Nurse (RN) Unit Manager on 7/25/12 at 9:45 AM, she stated that she was never told that the resident was self administering the Flonase until yesterday (7/24/12). She completed an assessment of the resident on 7/24/12 and determined that the resident was safe for self administration. However, the medication is supposed to be stored in a locked box in the resident's room. The resident refuses to use a locked box because he has difficulty opening the locked box. The physician gave an order for the resident to self administer the Flonase. The MAR was revised to reflect that the resident can self administer the Flonase.

415.3(e)(vi)

Based on record review and staff interviews during a recertificaton survey, the facility did not ensure that services provided or arranged for each resident met professional standards of quality. Specifically, one (Resident # 14) of 30 residents, reviewed for laboratory (lab) services, the physicians orders for Complete Blood Count (CBC) and BMP (basic metabolic panel) were not carried out.

This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

The Finding is:

Resident #14 was 65 years of age and admitted to the facility on 7/20/12 with diagnoses including Lumbar (5) compression fracture, spinal stenosis, bipolar disease, and peripheral vascular disease.

The physician's admission note dated 7/20/12 documented neurological status as alert and oriented x 3 (person, place, time).

The Medical Admission Physician Order set dated 7/20/12 documented Lab work- CBC and BMP every Tuesday.

Resident #14's medical record lacked documented evidence of CBC and BMP lab results for 7/24/12 (Tuesday).

During an interview with the 7:30 AM-3:30 PM Registered Nurse (RN) unit manager on 7/25/12 at 12:10 PM she looked for the lab results and stated that the lab work was not picked up by the float RN. She stated that the physician's order for the laboratory work should have been placed on a list for the unit secretary to complete the requisition form and the lab work would have been drawn up. She could not locate the resident's name on the list. She added that there is also another nurse that audits the orders to ensure accuracy (orders picked up).

During an interview with the 3:30 PM-11:30 PM float RN, she stated that she picked up the order and wrote it on the list in the lab book but the resident's name is not present now. She does not know how it happened.

415.11(c)(3)(i)

2000 NFPA 101 Life Safety Code Chapter 7.2.2.5.3 Usable Space- There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Based on observation and staff interview, stairways used as exits were not in accordance with 7.2 in that a hand truck, which does not serve the stairway, was observed being stored in the path of egress on the 2nd floor landing of Stair D.

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

The findings are:

On 7/25/12 at approximately 10:05am during the recertification survey, a hand truck was observed being stored in the path of egress on the 2nd floor landing of Stair D. There was no staff present in the stairway and the hand truck was not in use at the time of the observation. This configuration is contrary to the requirement of 7.2.2.5.3 that any open space within the enclosure shall not be used for any purpose that has the potential to interfere with egress.

In an interview on 7/25/12 at approximately 10:15am, the Quality Manager stated that the hand truck should not be in the 2nd floor stair well.

711.2(a)(1), 2000 NFPA 101- 7.2.2.5.3.