The Orchard Nursing and Rehabilitation Centre

Based on observation, staff interview and review of facility documents, it was determined that the facility did not promote care for residents in a manner that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality during the standard recertification survey. Specifically, for 1 observation the facility did not ensure that a call light was answered in a timely manner, and on 2 observations did not ensure that staff waited for a response from residents prior to entering their rooms. This resulted in no actual harm with a potential for more than minimal harm, which is not Immediate Jeopardy. This is evidenced by the following:

Resident # 16:
The facility did not ensure that a call light was answered in a timely manner.

The resident was admitted to the facility on 6/18/08 with diagnoses of kidney failure, osteoarthritis, and high blood pressure. MDS dated 6/25/11 assessed the resident to have moderately impaired cognition.

The Policy and Procedure (PP) for Call Lights dated 1/18/08, documented that no staff member of any department should walk by a room with a lighted call light unless it would risk the safety or dignity of another resident or staff person. When a call light was illuminated, staff were to respond promptly and meet the resident's needs (within that staff member's scope of practice). If unable to meet the resident's needs, the light was to be left on and someone who could help was to be located.

During an observation on 8/10/11 from 9:15 am through 9:33 am, this resident's call light was illuminated and sounding. During the entire observation, a staff member was sitting next to the call bell system at the nurses station. A Licensed Practical Nurse (LPN) #6 was observed to walk past the residents room twice. LPN#6 was also observed to stand at the medication cart directly outside the resident's room for 11 minutes. No staff entered the resident's room until 9:33 am when CNA#5 entered the room.

During an interview on 8/10/11 at 9:36 am, the Rehabilitation Registered Nurse (RRN) stated that she had been sitting at the nurses station and heard the call bell going off but must have "zoned it out." She stated that nurses should answer call bells if the CNAs were not available.

During an interview on 8/10/11 at 9:40 am, CNA#5 stated that when she returned from her break, this resident's call light was going off so she went into the room to assist the resident. She stated that while she was on break another CNA was to watch her residents, but that CNA was in another resident's room. She also stated that the LPNs were also supposed to answer call lights.

During an interview on 8/10/11 at 10:13 am, RN#1 stated that any staff member who went by the resident's room while the call bell was going off should have stopped by to see what the resident needed, and that included LPNs. She stated that at some point, the nurse at the nurses station and/or the LPN outside the resident's room should have answered this resident's call light.

During an interview on 8/10/11 at 10:40 am, LPN#6 stated that she did not answer this resident's call light because she was concerned about running late with her medication pass and was focused on her tasks. LPN#6 stated that she should have at least asked what the resident needed and asked another staff member to assist the resident if necessary.

Finding :
During an interview on 8/10/11 at 1:50 pm a staff member knocked on the residents' door and entered the residents room before the resident could acknowledge the knock. The staff member stated she was sorry and closed the door.

The resident was asked at the time of the incident if staff enter before they are asked to, and the resident responded yes.

Finding:
During an interview on 8/10/11 at 2:35 pm a staff member knocked on the residents' door and entered the residents room before the resident could acknowledge the knock.

The resident was asked at the time of the incident if staff enter before they are asked to and the resident responded yes, usually it happens at the change of shift.

During an interview on 8/11/11 at 8:30 am the perdiem Registered Nurse (RN) stated the staff should wait for the resident to acknowledge them before entering the room.

10 NYCRR 415.5(a)

Based on observation and staff interview, during the standard recertification survey, the facility did not ensure that it established and maintained an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection during three observations ( Findings 1, 2, and 3). Specifically, the facility did not ensure that staff washed their hands, did not ensure that kitchen staff did not use a common nail brush for hand cleaning, and did not ensure that a food service worker changed gloves between touching equipment and handling food. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This was evidenced by:

Finding 1:

The Policy and Procedure (P&P) for Hand Hygiene dated 10/22/09, documented that hand washing was the most important tool in preventing the transmission of disease. The P&P described the procedure for handwashing but did not describe when staff were supposed to wash their hands.

During an observation on 8/10/11 at 8:25 am, Certified Nursing Assistant (CNA) #1 repositioned a resident, touching the resident's body and bed linens. The CNA then removed her gloves and went to the clean linen room where she handled clean linens, then returned to the resident's room. The CNA did not wash her hands after removing her gloves.

During an observation on 8/10/11 at 8:30 am, Certified Nursing Assistant (CNA) #2 repositioned a resident, touching the resident's body and bed linens. The CNA then went into another resident's room to reposition another resident. The CNA did not wash her hands after between residents.

During an interview on 8/11/11 at 8:39 am, the Registered Nurse (RN) #1 stated that the Infection Control Nurse was on vacation. She stated that staff were supposed to wash their hands after removing gloves and between resident care whether the gloves or their hands were visibly soiled or not.

Finding 2:

During an observation on 8/10/11 at 8:55 am, a nail brush was observed hanging above the handwash sink within the kitchen. The Food Service Director was questioned about this at this time, who stated that the nail brush was there when she got to the facility.

During an interview on 8/11/11 at 9:05 am, the dishwasher stated that staff used the nail brush and that it had been there for approximately four years.

Finding 3:

During an observation of the noon meal on 8/10/11 at approximately 11:45 am, the food service worker (FSW) that was serving meals from the steam table was observed wearing gloves. The dietary aides placed the residents meal ticket on the top of the steam table. The FSW placed her gloved hands on the metal cover of the team table to read the meal tickets. The FSW was then observed to place the garnish of spiced apples onto the residents plate with her hands. The FSW was also observed to open the refrigerator door and again placed the garnish on resident plates with her hands. The FSW did not change her gloves during these observations.

During the observation the Director of Nurses (DON) observed that the FSW was not changing gloves or practicing appropriate hand hygiene. The DON then obtained a pair of tongs for the FSW so that her hands would not have to touch the garnish being applied to the residents plate.

10 NYCRR 415.19(a)(1-3)

Based on medical record review and staff interviews during the annual recertification survey, it was determined that the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. Specifically, for 2 ( #'s:10 and 18) of 17 residents reviewed the facility did not ensure accurate and complete documentation of bowel movements, interventions required to induce bowel movements and skin tracking forms. This is evidenced by the following:

1. Resident #10:
The facility did not accurately document the bowel movements and interventions required to induce bowel movements. Additionally, skin tracking forms were signed by nurses but lacked the condition of the skin at the time of the weekly tracking.
The resident was admitted to the facility with diagnoses of dementia, stroke and hypertension. The Minimum Data Set (MDS) dated 6/16/11 assessed the resident to have severe cognitive impairment.
The facility policy titled Bowel Care Management dated 9/09, documented that the day medication nurse reviews the Certified Nurse's Aide (CNA) daily flow sheet for each resident, identifying all residents who have not had a bowel movement in two days. The list will be given to the evening medication nurse during report at change of shift.

The evening medication nurse will be responsible for giving each of the resident identified on the bowel care management list Milk of Magnesia (MOM) 30 cubic centimeters (cc) by mouth schedule at 6:00 pm (typical results are 30 minutes to six hours). The nurse will place her initials on the list and the Medication Administration Record (MAR) after giving the MOM. The nurse will also check tos see if any residents identified on the laxative list have had a bowel movement prior to the end of the evening shift, noting this where indicated on the MAR (0=no results, small, medium or large). The list will be given to the night medication nurse during report at change of shift.

The night medication nurse will be responsible for giving each of the residents identified on the bowel care management list, who did not have any results, as noted on the MAR (small results will be counted as zero) a rectal suppository scheduled at 6:00 am (results are typically 15 minutes to one hour.) The nurse will place her initials in the appropriate column on the list and in the MAR after giving the suppository. All results will be documented on the MAR (0= no results, small, medium, large). The list will be given to the Nurse Manager/designee during report at change of shift.

The nurse manager/designee will be responsible for ensuring that a fleet enema per rectum is given (may be given by the CNA) to each resident who did not have any results from the suppository as noted on the MAR (small results will be counted as zero). The fleet enema will be given during morning care unless directed by the nurse manager/designee (results are typically 2 - 15 minutes.) The nurse manager/designee will sign their initials noting that the enema was given on the list, on the MAR, and document the name of the administering CNA on the back of the MAR. All results will be documented on the MAR (0=zero, small medium, or large).
The nurse manager/designee will review the bowel care management list in the afternoon. In the event that a resident has not had results from the above bowel regiment, (small will be counted as zero), the physician will be called for further orders and this will be documented.
The nurse manager/designee will review and give the completed bowel care management list to the Assistant Director of Nursing/designee. The completed bowel care management list will then be used as part of audit to report to the Quality Assurance/Quality Indicator Committee if indicated. The bowel care management list will be used daily. All MAR documentation will be completed by the nurse.
Physician order's for June 2011, documented the following bowel protocol: MOM 30 cc by mouth as needed at 6:00 pm if no bowel movement (BM) in 48 hours. Dulcolax suppository 10 milligrams (mg) by rectum once daily as needed at 6:00 am if no results from MOM. Fleet enema one by rectal route, enema to be administered if no results from the suppository.

The CNA Activities of Daily Living (ADL) flow sheet documented that the resident had bowel movements (BM) on 6/1, 6/2, 6/5, 6/11/ 6/18, 6/19, 6/28, 6/30, 7/3, 7/5, 7/7, 7/10, 7/13, 7/14, 7/17, 7/20, 7/24, 7/27, 7/28 and 7/29.

The MAR had documented the resident received medication to induce a BM on the following dates: 6/3 MOM at 4:24 pm with one BM result, 6/4 MOM at 3:46 pm with no BM result, 6/5 Dulcolax at 6:03 am with no BM result, 6/19 at 5:58 am Dulcolax with no BM result, 6/22 at 6:28 pm MOM with no results, 6/23 Dulcolax with one BM result, 6/26 at 3:38 pm MOM with no BM result, 6/27 at 6:11 am Dulcolax with one BM result, 7/3 at 6:23 Dulcolax with no BM result, 7/16 10:02 pm MOM with one BM result, 7/17 at 7:02 am Dulcolax with one BM result, 7/29 Dulcolax at 5:58 am with one BM result, 7/24 Dulcolax at 7:19 am with one BM result and 7/27 at 12:25 pm one Fleet enema with one BM result.
The bowel care management list documented the resident received the following: 6/3 MOM, Dulcolax and Fleet enema, 6/4 MOM, Dulcolax and Fleet enema, 6/15 Fleet enema, 6/18 MOM, Dulcolax and Fleet enema, 6/22 MOM, 6/26 MOM, 6/29 MOM and Dulcolax, 7/2 MOM, Dulcolax and Fleet enema, 7/12 Dulcolax and Fleet enema, 7/16 MOM, Dulcolax and Fleet enema, 7/19 MOM, Dulcolax and Fleet enema, 7/20 MOM, 7/23 MOM, Dulcolax and Fleet enema, 7/26 Dulcolax and Fleet enema, 7/31 MOM.
Examples of the discrepancies included but are not limited to the following, the MAR did not have documented evidence of a Dulcolax and Fleets enema having been administered on 6/3/11 or 6/4/11 as documented on the bowel care management list. The 6/15/11 Fleet enema and the 6/18/11 MOM, Dulcolax and Fleet enema are not documented on the MAR, but are documented on the bowel care management list
The bowel care management list did not have documented evidence of the 6/5/11 Dulcolax at 6:03 am with no BM result, or the 6/19/11 at 5:58 am Dulcolax with no BM result.
The CNA Activities of Daily Living (ADL) flow sheet had no BM documented on 6/3/11 and 6/23/11, however the MAR for these dates documented BMs by the resident.

Additionally,a facility form titled "Weekly Skin Check Flow Sheet" documented that the resident's skin was checked weekly from 3/2/11 through 8/9/11 but did not document the condition of the skin. The check boxes for Skin Intact, Existing Skin Issue, or Indicate New Area Location on Pictograph were not completed for 21 of 23 weeks.
During an interview on 8/10/11 at 1:30 pm RN #2 stated that the skin check sheets should have documented the condition of the skin when it was checked.
During an interview on 8/10/11 at 3:30 pm RN #1 stated that the bowel protocol was not documented as ordered by the physician.
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Residents #18:

The resident was admitted on 7/2/04 with the diagnoses of pressure sores, neurogenic bladder, and high blood pressure. The MDS dated 8/4/11 assessed the resident to be cognitively intact, and as having a pressure sore.

The Activities of Daily Living (ADL) Certified Nurses Aide (CNA) Care Plan dated 7/26/11, which the CNAs used to know the care each resident required, documented that the CNAs were to get a nurse to check the resident's skin when the resident was being showered.

The Comprehensive Care Plan (CCP) for At Risk Skin Care dated 4/26/11, documented that the resident was at risk for skin breakdown due to decreased mobility and urinary incontinence. The resident's skin was to be assessed every shift during ADL care.

Review of the Weekly Skin Check Flow Sheet for this resident revealed that the form was signed but the check boxes for Skin Intact, Existing Skin Issue, or Indicate New Area Location on Pictograph were not completed for the following dates: 5/3/11, 5/6/11, 5/10/11, 5/13/11, 5/17/11, 5/20/11, 6/7/11, 6/10/11, 6/21/11, 6/28/11, 7/8/11, and 7/15/11.
During an interview on 8/10/11 at 1:30 pm RN #2 stated that the skin check sheets should have documented the condition of the skin when it was checked.

10 NYCRR 415.22(a)(1)(2)

Based on medical record review and staff interviews during the standard recertification survey, it was determined that the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical needs that are identified in the comprehensive assessment. Sp ecifically, for 1 ( #10) of 17 resident reviewed who required several bowel interventions, there was no individualized plan of care in place with measurable goals. This resulted in no harm with the potential for more than minimal harm. This is evidenced by the following:

1. Resident #10:
The facility did not ensure that an individualized care plan regarding bowel elimination was developed with measurable goals.
The resident was admitted to the facility with diagnoses of dementia, stroke and hypertension. The Minimum Data Set (MDS) dated 6/16/11 assessed the resident to have severe cognitive impairment.
Physician order's for June 2011, documented the following bowel protocol: Milk of Magnesia (MOM) 30 cc by mouth as needed at 6:00 pm if no bowel movement (BM) in 48 hours. Dulcolax suppository 10 milligrams (mg) by rectum once daily as needed at 6:00 am if no results from MOM. Fleet enema one by rectal route, enema to be administered if no results from the suppository.

The medication administration record (MAR) documented that the resident received medications to induce a BM on the following dates: 6/3 MOM at 4:24 pm with one BM result, 6/4 MOM at 3:46 pm with no BM result, 6/5 Dulcolax at 6:03 am with no BM result, 6/19 at 5:58 am Dulcolax with no BM result, 6/22 at 6:28 pm MOM with no results, 6/23 Dulcolax with one BM result, 6/26 at 3:38 pm MOM with no BM result, 6/27 at 6:11 am Dulcolax with one BM result, 7/3 at 6:23 Dulcolax with no BM result, 7/16 10:02 pm MOM with one BM result, 7/17 at 7:02 am Dulcolax with one BM result, 7/29 Dulcolax at 5:58 am with one BM result, 7/24 Dulcolax at 7:19 am with one BM result and 7/27 at 12:25 pm one Fleet enema with one BM result.

The bowel care management list documented the resident received the following: 6/3 MOM, Dulcolax and Fleet enema, 6/4 MOM, Dulcolax and Fleet enema, 6/15 Fleet enema, 6/18 MOM, Dulcolax and Fleet enema, 6/22 MOM, 6/26 MOM, 6/29 MOM and Dulcolax, 7/2 MOM, Dulcolax and Fleet enema, 7/12 Dulcolax and Fleet enema, 7/16 MOM, Dulcolax and Fleet enema, 7/19 MOM, Dulcolax and Fleet enema, 7/20 MOM, 7/23 MOM, Dulcolax and Fleet enema, 7/26 Dulcolax and Fleet enema, 7/31 MOM.

During an interview on 8/10/11 at 3:30 pm RN #1 stated that there was no care plan for bowel elimination for this resident.
10NYCRR 415.11(c)(1)

Based on medical record review and staff interviews during the standard recertification survey, it was determined that the facility did not ensure that services provided or arranged met professional standards of quality. Specifically, for 2 ( #'s 10, 16 ) of 17 residents reviewed geri-sleeves were not applied as planned, and the physician ordered bowel protocol was not followed. This resulted in no harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:
1. Resident #10:
The facility did not follow the bowel protocol as ordered by the physician.
The resident was admitted to the facility with diagnoses of dementia, stroke and hypertension. The Minimum Data Set (MDS) dated 6/16/11 assessed the resident to have severe cognitive impairment.
The facility policy titled Bowel Care Management dated 9/09, documented that the day medication nurse reviews the Certified Nurse's Aide (CNA) daily flow sheet for each resident, identifying all residents who have not had a bowel movement in two days. The list will be given to the evening medication nurse during report at change of shift.

The evening medication nurse will be responsible for giving each of the resident identified on the bowel care management list Milk of Magnesia (MOM) 30 cubic centimeters (cc) by mouth schedule at 6:00 pm (typical results are 30 minutes to six hours). The nurse will place her initials on the list and the Medication Administration Record (MAR) after giving the MOM. The nurse will also check to see if any residents identified on the laxative list have had a bowel movement prior to the end of the evening shift, noting this where indicated on the MAR (0=no results, small, medium or large). The list will be given to the night medication nurse during report at change of shift.

The night medication nurse will be responsible for giving each of the residents identified on the bowel care management list, who did not have any results, as noted on the MAR (small results will be counted as zero) a rectal suppository scheduled at 6:00 am (results are typically 15 minutes to one hour.) The nurse will place her initials in the appropriate column on the list and in the MAR after giving the suppository. All results will be documented on the MAR (0= no results, small, medium, large). The list will be given to the Nurse Manager/designee during report at change of shift.

The nurse manager/designee will be responsible for ensuring that a fleet enema per rectum is given (may be given by the CNA) to each resident who did not have any results from the suppository as noted on the MAR (small results will be counted as zero). The fleet enema will be given during morning care unless directed by the nurse manager/designee (results are typically 2 - 15 minutes.) The nurse manager/designee will sign their initials noting that the enema was given on the list, on the MAR, and document the name of the administering CNA on the back of the MAR. All results will be documented on the MAR (0=zero, small medium, or large).

The nurse manager/designee will review the bowel care management list in the afternoon. In the event that a resident has not had results from the above bowel regiment, (small will be counted as zero), the physician will be called for further orders and this will be documented.

The nurse manager/designee will review and give the completed bowel care management list to the Assistant Director of Nursing/designee. The completed bowel care management list will then be used as part of audit to report to the Quality Assurance/Quality Indicator Committee if indicated. The bowel care management list will be used daily. All MAR documentation will be completed by the nurse.

The Physician order's for June 2011, documented the following bowel protocol: MOM 30 cc by mouth as needed at 6:00 pm if no bowel movement (BM) in 48 hours. Dulcolax suppository 10 milligrams (mg) by rectum once daily as needed at 6:00 am if no results from MOM. Fleet enema one by rectal route, enema to be administered if no results from the suppository.

The CNA Activities of Daily Living (ADL) flow sheet documented that the resident had bowel movements (BM) on 6/1, 6/2, 6/5, 6/11, 6/18, 6/19, 6/28, 6/30, 7/3, 7/5, 7/7, 7/10, 7/13, 7/14, 7/17, 7/20, 7/24, 7/27, 7/28 and 7/29.

The MAR documented that the resident received medications to induce a BM on the following dates: 6/3 MOM at 4:24 pm with one BM result, 6/4 MOM at 3:46 pm with no BM result, 6/5 Dulcolax at 6:03 am with no BM result, 6/19 at 5:58 am Dulcolax with no BM result, 6/22 at 6:28 pm MOM with no results, 6/23 Dulcolax with one BM result, 6/26 at 3:38 pm MOM with no BM result, 6/27 at 6:11 am Dulcolax with one BM result, 7/3 at 6:23 Dulcolax with no BM result, 7/16 10:02 pm MOM with one BM result, 7/17 at 7:02 am Dulcolax with one BM result, 7/29 Dulcolax at 5:58 am with one BM result, 7/24 Dulcolax at 7:19 am with one BM result and 7/27 at 12:25 pm one Fleet enema with one BM result.

The bowel care management list documented the resident received the following: 6/3 MOM, Dulcolax and Fleet enema, 6/4 MOM, Dulcolax and Fleet enema, 6/15 Fleet enema, 6/18 MOM, Dulcolax and Fleet enema, 6/22 MOM, 6/26 MOM, 6/29 MOM and Dulcolax, 7/2 MOM, Dulcolax and Fleet enema, 7/12 Dulcolax and Fleet enema, 7/16 MOM, Dulcolax and Fleet enema, 7/19 MOM, Dulcolax and Fleet enema, 7/20 MOM, 7/23 MOM, Dulcolax and Fleet enema, 7/26 Dulcolax and Fleet enema, 7/31 MOM.

Progress notes written on 7/20/11 documented that the resident received a fleets enema with minimal results. There was no further documentation provided regarding BM's.
In summary, the bowel protocol was documented as being implemented on days when it should not have been and it was documented that the bowel protocol was not implemented as written by the physician.
During an interview on 8/10/11 at 3:30 pm RN #1 stated that the bowel protocol was not followed as written by the physician.

Resident # 16:
The facility did not ensure that protective arm sleeves were applied to the resident as care planned.

The resident was admitted to the facility on 6/18/08 with diagnoses of kidney failure, osteoarthritis, and high blood pressure. The MDS dated 6/25/11 assessed the resident to have moderately impaired cognition.

The Comprehensive Care Plan (CCP) for At Risk for Skin Impairment dated 2/15/11, documented that the resident was at risk for impaired skin integrity due to a skin tear on her left elbow.

The Activities of Daily Living (ADL) Certified Nurses Aide (CNA) Care Plan dated 7/27/11, which the CNAs used to know the care each resident required, documented that the resident was to have protective arm sleeves on at all times and that they were to be off only while the resident was receiving care.

During observations on 8/10/11 at 9:15 am, and at 10:35 am, the resident was sitting in a wheel chair in her room. There was no staff present and the resident was not wearing protective arm sleeves.

During an observation on 8/11/11 at 11:25 am, the resident was sitting in a wheel chair in the dining room. The resident was not wearing protective arm sleeves.

During an interview on 8/10/11 at 11:27 am, CNA#4 stated that the resident was supposed to have protective arm sleeves on at all times. She did not know why the resident did not have them on, and searched the resident's room and could not find them. CNA#4 stated that she would have to get another pair for the resident.

During an interview on 8/10/11 at 10:13 am, Registered Nurse (RN) #1 stated that if protective arm sleeves were part of the plan of care for this resident, she should have had them on.

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

Based on staff and resident interview the facility did not ensure the resident had the right to manage his or her financial affairs during the standard recertification survey. Specifically, 8 of 8 residents that attended the NYSDOH Resident Group Meeting indicated that money could not be obtained on the weekends. This caused no actual harm but had potential for minimum harm. This is evidenced by the following information:

Finding 1:
During the Resident Meeting on 8/10/11 at 10:00 am eight of the eight residents in attendance stated that money was not available on the weekends.

Four residents that attended the group meeting were then reinterviewed individually. Three of the four residents stated they would be interested in being able to obtain money on the weekends.

During an interview on 8/11/11 at approximately 10:30 am the Administrator stated that was the practice. He stated arrangements were being made to have cash available if the residents requested it.

10NYCRR 415.3(g)(1)