Ira Davenport Memorial Hospital Snf/hrf

Based on observations, staff interviews, and record review, it was determined that for 1 of 14 residents reviewed for quality of care, the facility did not provide the necessary care and services to meet the residents' highest level of physical functioning. The issue involved lack of an effective bowel management program for Resident #5. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following:

Resident #5 was admitted to the facility on 2/18/08 with diagnoses including Alzheimer's Disease and diabetes and readmitted to the facility on 10/2/09 after hospitalization for a fecal (stool) impaction. The Minimum Data Set (MDS) Assessment, dated 10/7/09, revealed that the resident's cognitive skills for daily decision making were moderately impaired. Also, the resident was non-ambulatory and totally dependent upon staff for feeding and toileting.

The Comprehensive Care Plan, dated 10/2/09, included constipation as a problem. The plan included a regular time for elimination, preferably after breakfast, high fiber foods, eight to ten glasses of fluid daily, to encourage activity, and Range of Motion as tolerated.

The facility's August 2007 policy regarding Routine Bowel care includes that all residents will have standing orders upon admission for routine bowel care unless contraindicated. If after three days the resident had not had a BM of medium or large size, the resident would receive 30 ccs of MOM on the third evening. If this does not induce a BM by the morning of the fourth day, the resident would receive a Ducolax suppository rectally. If the suppository does not induce a BM within two hours, a Fleets enema would be given. If there were no results from the Fleets enema, MOM would be repeated that evening, and a tap water enema would be given. Additionally, this regime will be modified to meet the resident's individual needs.

The June 2009 bowel records revealed that the resident did not have a BM for ten shifts from 6/9 until 6/11/09 on the evening shift where the record was marked "results pending." A medium BM was recorded on the evening of 6/12/09. The June 2009 MAR included an entry on 6/11/09 for Milk of Magnesia (MOM) given on the evening shift and marked "results pending." The June 2009 MAR lacked evidence to show that any other bowel medications were given at this time.

The August through September 2009 bowel records revealed that the resident did not have a BM for 13 shifts from 8/29 to 9/2/09. On 9/2/09, 30 ccs of MOM was given on the evening shift with results pending, the resident had a medium BM on 9/3/09 in the morning.

The computerized nursing notes dated from 8/14/09 - 8/22/09, 8/24/09- 8/27/09, and on 9/4/09 revealed that the resident had a poor intake for food and fluids and needed much encouragement with meals.

A 9/6/09 nursing progress note recorded that the resident was complaining that her stomach hurt and that she "couldn't poop." A Fleets enema was given with no results. A second Fleets enema was given at 1:30 a.m. with no results noted. This same note included that the resident was full of hard stool, and at 3:00 a.m. that day the resident was given a tap water enema with results.

An entry dated 9/28/09 on the September 2009 MAR revealed that a Fleets enema was given at 4:45 a.m. with large results.

A 9/28/09 nursing progress note entered at 5:06 a.m. by a Licensed Practical Nurse (LPN) revealed that when the resident complained "it hurts," and was noted to have hard stool, a Fleets enema was given with large results.

A progress note entered at 3:50 a.m., dated 9/29/09, written by the nursing supervisor that upon assessment the resident had large mahogany (red) colored blood clots in her incontinence brief and a large ball of stool remaining in the rectum.

A 9/29/09 LPN progress note revealed that when apprised of the results of the rectal exam, the physician gave directions to admit the resident to the hospital to rule out a gastrointestinal (GI) bleed. Additionally, the resident was transported to the hospital at approximately 9:41 a.m.

A medical surgical consult note, dated 9/29/09, inlcuded "insignificant lower GI bleeding probably related to stool impaction." A radiologist's documented impression of a 9/29/09 abdominal scan revealed a significant fecal distention of the colon.

During a lunch meal observation on 12/7/09 at 12:20 p.m., the resident was seated in a geri chair in the dining room with her eyes closed. While being fed by a Certified Nursing Assistant (CNA), the resident refused pureed food, took a few sips of Ensure (beverage supplement), and ate 1/2 of her 4 ounce (oz) cup of ice cream and stated, "It tastes good."

When observed during the breakfast meal on 12/9/09 at 8:00 a.m., the resident was in bed being fed by a CNA. The resident ate two bites of pureed toast and refused the third bite. She drank 8 oz. of Ensure, 2 oz. of orange juice, and 6 oz. of whole milk.

When interviewed on 12/8/09 at 4:45 p.m., the Registered Nurse (RN) Nurse Manager (NM) stated that all residents have standing orders for a bowel regime protocol on admission unless contraindicated. In addition, the policy includes that if a resident does not have a BM after nine shifts, the Routine Bowel Care policy will be initiated. The policy includes beginning with 30 ccs of MOM and, if no results by the next shift, the resident will receive a Dulcolax suppository. If no results after two hours, then a Fleets enema is given. If no results, then MOM will be repeated and a tap water enema is given.

During an interview on 12/9/09 at 1:35 p.m., the Director of Nursing (DON) stated that the resident should have received a Ducolax suppository on the 6/11/09 night shift if there were no results from the MOM given on the 6/11/09 evening shift. She could not tell if there had been results from the MOM that evening due to lack of documentation.

When interviewed on 12/9/09 at 1:30 p.m., the Dietary Technician (DT) stated that she had not specifically addressed the bowels in a progress note. She added that dietary could have provided notice to the staff to be aware and encourage prune juice between meals and at bedtime. She stated that usually if a resident has a problem with constipation, she would increase the fluids. She added, "I guess I just missed it, I was so worried about her weights and skin."

When interviewed on 12/10/09 at 8:45 a.m., the attending physician stated that he was unaware that the resident went greater than nine shifts without a BM during June, August, and September 2009. When asked about the bowel protocol, the physician said that if it had been followed the resident may not have sustained a fecal impaction.

When interviewed on 12/10/09 at 11:30 a.m., the RN/NM stated that on 9/2/09 and on 9/28/09 the night nurse gave two Fleets enema and a tap water enema. Also, the night nurse did not follow the bowel regime policy and has been reeducated.

[10 NYCRR 415.12]

Based on observations and staff interviews, it was determined the facility did not store, prepare, distribute, and serve food under sanitary conditions in the Main Kitchen. Issues included improper cleaning and sanitizing of food contact surfaces, spoiled food, improper cleaning of non-food contact surfaces, and lack of maintenance of physical features. This resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Observations made during the kitchen tour with the Department Manager (DM) on 12/7/09 at approximately 10:00 a.m. through 11:50 a.m. revealed the following:

1. Food contact surfaces were not properly cleaned, sanitized, and air dried. The meat slicer was noted to have accumulations of food on the cutting blade, on the cutting wall, and around the base. The Robo-coupe had dried food on the blade and was stored wet. The large floor mixer had food crumbs in its large stainless steel bowl and drips and splatters around the mixing equipment. The surface of the small mixer located by the slicer table, was soiled with dried food drips. The surfaces of the submersible blender at the prep area was soiled with dried food accumulations and was stored wet. A 1/2 gallon pitcher hanging at the cook's area was stored wet. At this time, the DM stated that all these items were ready for use.

Three of three sanitizer buckets, located at the cook's table, the prep area, and the slicer table, contained sanitizer at less than the required 200 parts per million.

2. Spoiled food held in the walk-in cooler included one moldy tomato and three moldy cucumbers. At the prep area, a dried husk of a potato was observed in the bin with the other potatoes. The onion basket had a thick layer (as deep as 2 inches) of old dried onion skins.

3. Non-food contact surfaces were not clean. There was mold present on the walk-in cooler fan louvers and a Jello spill down the wall of the cooler from a tray rack. This spill traveled down the rack, over a scrambled egg mix and 4 oz. juice containers. The bowl dolly near the "disher" area was noted to have food crumbs under the bowls. Tableware, two of three condiment trays, and straw trays at the tray-line contained debris and food crumbs. Two of two steam tables folding shelves were noted to have dried food accumulations.

4. At approximately 10:54 a.m., a dead cockroach was observed in the steam table water bay. A pan of green beans to be served at the lunch meal were located next to this steam table bay. The water in the steam table bay also contained food debris from the morning meal service. Four of four floor drains throughout the kitchen were observed to have thick accumulations of food and cobwebs. The floor drain in front of the walk-in freezer contained a dead cockroach. In the dishroom, under the dish-machine, 40 dead cockroach bodies were observed. Some of these were floating in water on the floor under the dishmachine. One live cockroach nymph (baby) was observed near the ceiling above the spray handle area.

5. An empty open electrical box was located in the wall under the dish machine. This box held old, wet food debris and ten dead cockroaches. Under the three bay sink, three dead cockroaches floated in water. In the condenser room located off the dishroom, walls were in disrepair. Ten dead cockroaches and food debris were on the floor. An opening was visible into the wall by the three bay sink where a stainless steel sheet did not meet the floor cove molding.

6. The rain water drain line from the roof, located next to the trayline, was observed to have what appeared to be black oozing drops coming out of the pipe. These drips had dried and were flaking onto the trayline tray rollers.

[10 NYCRR 415.14(h) ; Chapter 1 State Sanitary Code Subpart 14-1: 14-1.31(a), 14.1.90, 14-1.110, 14-1.116, 14-1.117, 14-1.160, 14-1.71]

Based on observations, record review, and staff interviews, it was determined that for three of eight care observations, facility staff did not use appropriate infection control techniques. The issue involved the lack of adequate hand hygiene and/or glove changing during provision of personal care and hygiene and dressing change. This affected Residents #11, #12, and #14, resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #14 has diagnoses including congestive heart failure, a Stage IV sacral pressure ulcer, and a history of clostridium difficile (bacteria) infection. The Minimum Data Set (MDS) Assessment, dated 9/10/09, revealed that the resident's cognitive skills for daily decision making are modified. The Patient's Care Plan, dated 12/8/09, revealed that the resident can assist with some parts of his care. The undated Certified Nurse Aide (CNA) Assignment Sheet revealed that the resident requires the assistance of two for bathing.

During a care observation on 12/8/09 at 9:30 a.m., CNA #1 washed her hands for eight seconds, applied gloves, bathed the resident, did Foley catheter care, and cleansed bowel movement (BM) from the rectal area. CNA #1 then placed a brief under the resident and took the resident's arm and assisted the resident to turn. CNA #1 removed her gloves and washed her hands for nine seconds, reapplied gloves, and dressed the resident.

When interviewed on 12/8/09 at 1:15 p.m., CNA #1 stated she would do Foley catheter care, change gloves, and then cleanse the rectal area before removing her gloves. She stated the gloves are soiled so she would wash her hands for one minute after removing them.

When interviewed on 12/8/09 at 1:35 p.m., the Unit A Registered Nurse (RN) Manager stated that when doing peri rectal care staff should apply gloves, cleanse the resident, then remove gloves and wash hands for 15 seconds.

In addition, the Hospital History and Physical, dated 8/18/09, revealed that the resident's pressure ulcers were cultured and grew Proteus and Klebsiella bacterias. The Physician Order Sheet, dated 10/17/09, included an Aquacel Ag (silver impregnated antimicrobial dressing) to the coccyx area.

When observed on 12/8/09 at 9:55 a.m., the Charge Licensed Practical Nurse (LPN) washed her hands, applied gloves, and removed the dressing from the resident's sacral area. The LPN cleansed the area, which was soiled from stool incontinence. The LPN then removed her gloves and washed her hands for seven seconds, reapplied gloves and applied Aquacel AG directly into the pressure ulcer with her gloved hand and then covered it with a dressing. The LPN applied an incontinence brief and pulled up the resident's pants. She then removed her gloves and put the electric bed down, put a sheet and blankets over the resident, and opened the privacy curtain before washing her hands for ten seconds.

When interviewed on 12/8/09 at 1:20 p.m., the Charge LPN stated that after applying the sacral dressing, she should have removed her gloves before touching other items in the room and washed her hands for 30 seconds.

When interviewed on 12/8/09 at 1:40 p.m., the Unit A RN Manager stated after doing a pressure ulcer dressing change, gloves should be removed, and hands washed for 15 seconds. She was not aware that the LPN did not take off her gloves after doing the dressing.

2. Resident #11 has diagnoses including diabetes mellitus. The MDS Assessment, dated 10/21/09, revealed the resident's cognitive skills for daily decision making were moderately impaired and that the resident had a urinary tact infection in the past 30 days. The Patient Care Plan, dated 10/21/09, revealed the resident is incontinent. The CNA Assignment Sheet, undated, indicated that the resident requires the total assistance of one for personal care and toileting.

An observation on 12/8/09 at 9:10 a.m., revealed that the resident's pants were soiled with urine. CNA #2 applied gloves and removed the resident's pants and brief, then removed her gloves and obtained clean pants. CNA #2 then washed her hands for seven seconds and reapplied gloves, cleansed the resident's peri rectal area, removed gloves, and washed her hands for ten seconds.

When interviewed on 12/8/09 at 1:25 p.m., CNA #2 revealed that she usually removes gloves after peri rectal care and sings "Happy Birthday" while she is washing her hands. Also, she should have taken off her gloves after cleansing the rectal area.

3. Resident #12 has diagnoses including cerebral vascular accident and left hemiparesis (stroke with left sided weakness). The MDS Assessment, dated 10/23/09, revealed the resident's cognitive skills for daily decision making were moderately impaired. The Patient Care Plan, dated 10/27/09, revealed that the resident is incontinent and dependent for peri-care. The undated CNA Assignment Sheet revealed that the resident needs the assistance of one for personal care and two assist for toileting.

When observed on 12/8/09 at 8:56 a.m., the resident was incontinent of urine and BM. CNA #3 applied gloves and cleansed BM from the resident's rectal area by folding the disposable wipe over. BM came in contact with the CNA's gloved hand. CNA #3 then removed a gait belt from around the resident's waist and reapplied it, stood the resident, and continued to cleanse BM from the resident's rectal area. She then applied the resident's brief and pants before removing her gloves and washing her hands.

When interviewed on 12/8/09 at 12:55 p.m., CNA #3 stated you should remove gloves after cleansing the rectal area or if gloves are soiled with BM and then wash hands. She stated, "Oh, I forgot to remove my gloves before taking off the gait belt."

When interviewed on 12/8/09 at 4:05 p.m., the Unit B RN Manager stated after doing peri-rectal care, the gloves should be removed and hands washed for 15 seconds before touching anything else.

The facility's Hand Hygiene Policy, dated April 2008, directs staff to "Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled," and "after removing gloves." Directions for handwashing were to wash hands with soap and water, and to rub hands together vigorously for at least 15 seconds.

[10 NYCRR 415.19(b)(4)]

Based on an observation made during the Life Safety Code Survey, it was determined that a means of egress was not maintained free of potential obstructions at all times. Issues include boxes of resident clothing stored in an exit stairwell. This affected one of two basement exit stairwells, and resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is:

On 12/7/09 at approximately 2:00 p.m., ten large boxes of resident clothing were observed stored in the basement east stairwell. An exit enclosure cannot be used for any purpose that has the potential to interfere with its use as an exit.

[2000 NFPA 101 19.2.1, 7.1.3.2.3, 7.2.2.5.3: 1997 NFPA 101: 13-2.1, 5-1.3.2.3, 5-2.2.5.3; 10 NYCRR 415.29(a)(2), 711.2(a)(1)]