Elderwood Health Care at Maplewood

Based on observation, record review and staff interview, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infection. One (Resident #5) of four residents observed for incontinence care had issues involving lack of proper hand hygiene and glove removal after providing incontinence care and the placement of fecal soiled linen directly on the floor. In addition, one (Unit 2) of four nursing units had an unclean shower room. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #5 was readmitted 4/27/11 with a diagnosis of a right hip fracture with surgical repair. Review of the Minimum Data Set (MDS) dated 3/9/11 revealed the resident is incontinent of stool and requires assistance for toileting and personal hygiene.

Observation on 5/3/11 at 9:30 AM revealed the resident was assisted to the toilet by two Certified Nurse Aides (CNAs #1,2). While the resident was standing at the grab bar with the assistance of CNA #1, CNA #2 (while wearing gloves) cleansed the resident's buttocks of a moderate amount of stool and then set the three fecal soiled washcloths on the bare bathroom floor. CNA #2 then assisted the resident in her wheelchair, adjusted her clothes and fastened the seat belt without removing the soiled gloves or washing her hands. The resident was transported out of the bathroom by CNA #1, CNA #2 picked up the soiled linen and deposited it in the dirty utility room appropriately and washed her hands. The bathroom floor was not observed to be cleaned after the fecal soiled washcloths were removed from the floor and housekeeping was not notified at this time.

During an interview on 5/5/11 at 7:15 AM, the Licensed Practical Nurse (LPN) Unit Manager (UM) stated that she expects staff to remove their gloves after incontinence care before touching any clothes or environmental surfaces and that soiled linen should never be placed on the floor but on a pad, garbage bag or even paper towel as per facility policy.

Interview with CNA #4 on 5/5/11 at 10:30 AM revealed the gloves should be removed immediately after incontinence care and before touching a resident's clothes or any clean surface. The CNA explained they are taught to put soiled linen on a blue pad or towel but never on the bare floor and if she did she would call housekeeping immediately.

Review of a facility policy and procedure (P&P) entitled Nursing Service Perineal (the area between the genitalia and rectum)/ Incontinence Care dated 8/00 revealed staff are required for infection control to "discard gloves and wash hands thoroughly" after providing perineal care.

2. Observations of the Unit 2 Bathing Suite on 5/2/11 at 6:40 PM and on 5/3/11 at 7:05 AM revealed a shower chair located in the shower room had a large piece of brown debris (2 to 3 centimeters (cm)) on the foot rest. There was another 2 to 3 cm piece of the same brown debris in the shower drain. The shower floor was damp but not wet.

When interviewed on 5/3/11 at 7:10 AM, CNA #3 stated that the "brown stuff looks like stool" and that "the CNAs are supposed to clean the shower chairs after each shower". The CNA stated the shower was not used yet this morning; the shift started at 6:00 AM and they don't usually give showers until after breakfast.

When interviewed on 5/3/11 at 7:15 AM, a Registered Nurse (RN) stated that the CNAs are to clean the shower chairs after each shower with the cleaning agent found in a box on the wall. The RN stated that the brown debris was most likely stool and she would notify housekeeping immediately.

415.19(a)(1)(4)(c)

Based on observation, record review, and staff and resident interview, the facility did not ensure that services provided by the facility were provided by qualified persons in accordance with each resident's written plan of care. Two (Residents #3, 5) of 22 residents reviewed for care plan implementation had issues involving heel booties that were not provided as planned and a resident who was transferred and ambulated without the use of an upper extremity sling in accordance with the care plan. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #5 was readmitted 4/27/11 with a diagnosis of left hip fracture following a fall.

Review of readmission Physician's Orders dated 4/27/11 revealed an order for Quell booties to both heels while in bed. Review of the Resident Profile of Care, used by certified nurse aides (CNAs) to provide care, dated 4/28/11 revealed an approach for the resident to wear Quell booties at all times.

Observations on 5/3/11 from 2:00 PM to 2:30 PM and on 5/4/11 at 12:30 PM revealed Resident #5 was lying in bed without heel booties on. The 5/3/11 observation revealed both of the resident's heels were lying on the bed and the 5/4/11 observation revealed the resident's right leg was on a pillow but the left leg was lying on the bed.

During an interview on 5/4/11 at 12:50 PM, the CNA assigned to the resident stated that she did not put the resident back to bed and did not know who did, but she (the resident) should have booties on.

When interviewed on 5/4/11 at 1:00 PM, the Licensed Practical Nurse (LPN) stated that yes the resident should be wearing booties at all times and the LPN was observed to put booties on the resident. The resident denied any heel pain at this time, but did cry out in pain when her legs were lifted to apply the booties.

An interview with the Registered Nurse (RN) on 5/4/11 at 1:10 PM revealed that the resident needs the booties on whenever she is in bed because she does not move her legs much.

Interview with the LPN Unit Nurse on 5/4/11 at 1:30 PM revealed that Resident #5 does not have any skin breakdown on the heels and that she wears the booties for preventive measures.

2. Resident #3 was admitted 11/23/10 with a diagnosis of a right arm fracture with surgical repair. Review of the Minimum Data Set (MDS) dated 3/2/11 revealed the resident is cognitively intact.

Review of Physician's Orders dated 4/1/11 revealed an order that the resident's right upper extremity was still non-weight bearing. Review of an Occupational Therapy (OT) Progress Note dated 3/30/11 revealed the resident continues on maintenance therapy twice weekly with recommendations for staff to continue non-weight bearing of the right upper extremity and to use a right upper extremity sling for transfers and ambulation.

Review of the current Nursing Care Plan dated 1/26/11 and the CNA Profile of Care dated 4/5/11 revealed a plan for the use of a right arm sling at all times for transfers and ambulation.

Observation on 5/3/11 at 10:00 AM revealed CNA #1 transferred the resident from her wheelchair to a shower chair and then back again and no sling was used.

When interviewed on 5/3/11 at 1:00 PM, CNA #1 stated that she only uses the resident's arm sling for ambulation, not transfers.

Observation on 5/4/11 at 12:45 PM revealed the resident was ambulating in the hall with the assistance of CNA #2. The resident was not wearing her arm sling, but was holding her right arm close to her body at a right angle and holding the walker with her left hand.

Interview with CNA#2 at this time revealed the resident does not like to use her sling and that it is her decision if she wears it or not. When asked if she informed the nurse of this, the CNA stated no but that she would.

When interviewed on 5/4/11 at 1:00 PM, the resident stated that no, they didn't ask her if she wanted the sling but that was okay with her, she didn't need it.

During an interview on 5/4/11 at 1:15 PM, the Registered Nurse (RN) stated that if a resident refused care per the care plan, the CNAs are to let the nurse (team leader) know and they are supposed to document this.

When interviewed on 5/4/11 at 2:20 PM, the Occupational Therapist stated that the resident is still being seen for maintenance and if the arm sling is still on her care plan, "they should still be using the sling". The Occupational Therapist explained that even though the resident doesn't always use the sling, the Therapist would not discontinue it without the order of her Orthopedic Surgeon.

Review of Nursing Progress Notes for the past month revealed 27 entries that documented that the resident was cooperative with care. There was no documentation that the resident refused care or the use of the sling.

415.11(c)(3)(ii)

Based on observation, record review, and staff and resident interview, the facility did not provide services in accordance with professional standards of quality. Two (Residents #5, 26) of 26 residents reviewed for professional standards of quality had issues involving laboratory blood work that was not done as ordered by the physician (#5) and a medicated pain patch that was removed by unlicensed personnel (#26). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #5 was readmitted 4/27/11 with diagnoses including a recent left hip fracture following a fall, diabetes mellitus, and hypothyroidism.

Review of readmission Physician's Orders dated 4/27/11 (Wednesday) revealed orders to obtain laboratory (lab) blood work including a CBC(complete blood count), a CMP (complete metabolic panel), and a TSH (thyroid stimulating hormone) to be drawn on the next lab day and then again in one week.

Review of the entire medical record on 5/4/11 revealed no documented evidence that any laboratory reports were received since the resident's readmission on 4/27/11.

During an interview on 5/4/11 at 2:00 PM, the Licensed Practical Nurse (LPN) Unit Manager (UM) stated that the facility's lab days are Monday, Wednesday and Friday indicating that three lab days had passed since Resident #5 was readmitted. The LPN UM stated Resident #5's lab work was never ordered. The LPN UM explained that the blood work order was missed by the Unit Clerk who was off that day and it wasn't picked up on the following days, so it was never drawn. The LPN Unit Manager stated she would let the Physician know and have it drawn immediately.

During an interview on 5/4/11 at 3:45 PM, the Director of Nursing (DON) stated it is the responsibility of the nurses on the unit to make sure the orders are taken off if a Unit Clerk is out. The DON stated the blood work order was put into the communication book by the nurse but it never got ordered. The DON stated that the missed blood work would most likely not have been identified until the Physician made his routine visit and went to review the lab work results.

When interviewed on 5/4/11 at 3:55 PM, the Unit Clerk stated that she was not aware that she had to order readmission lab work from Wednesday, when she came back to work on Friday.

2. Resident #26 was admitted 12/28/09 with diagnoses including Parkinson's disease, arthritis and right hip pain. Review of Physician's Orders dated 3/3/11 revealed an order for a 5 percent (%) Lidoderm patch (a topical anesthetic patch, used to cause loss of feeling in the skin and surrounding area) for right hip pain to be applied in the AM and removed at bedtime.

During observation of the medication pass on 5/2/11 at 9:20 PM, an LPN attempted to remove the Lidoderm patch from the resident's right hip but she could not find it. At this time, the resident stated that she had had the patch on, but a nurse already removed it.

When interviewed on 5/2/11 at 9:40 PM, the Certified Nurse Aide (CNA) assigned to the resident stated that "yes, I removed the patch when I put her to bed" (on 5/2/11). When asked if she always does this, the CNA stated that while the nurse did not ask her to remove the patch tonight, she (the CNA) does it routinely when she gets the residents ready for bed. The CNA stated that she was not aware that she was not supposed to remove the patch.

During an interview on 5/3/11 at 7:30 AM, the LPN UM stated that only licensed nurses are allowed to remove medicated patches, not CNAs, and that she had already counseled the CNA.

415.11(c)(3)(i)

415.26(b)(13) Organization and administration: Administration.

A nursing home shall be administered in a manner that enables 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 Governing Body shall notify the department immediately of anticipated or actual termination of any services vital to the continued safe operation of the facility or to the health and safety of its residents and personnel.

These requirements are not met as evidenced by:

STATE ONLY

Based on record review and staff interview, the facility did not notify the New York State Department of Health of anticipated or actual termination of services vital to the continued safe operation of the facility or to the health and safety of residents and personnel. The issue involved the interruption of water service resulting in the use of paper plates for three meals during a boiler replacement project and two fire/smoke events. There was a fire in the Laundry room and another fire in a rooftop air handler that both resulted in the fire alarm activating and onsite response from the local fire department. This was a pattern with no actual harm with potential for minimal harm.

The findings are:

1. Review of facility disaster drill records on 5/3/11 revealed a Loss of Hot Water Drill was conducted on 1/30/11 and 1/31/11 as a result of the loss of Hot Water Services to the Laundry and Kitchen Departments during a boiler replacement project. Interview with the Administrator on 5/5/11 at approximately 10:20 AM revealed paper plates were used for three meals (Breakfast, Lunch and Dinner) on 1/31/11 during the boiler replacement project. The Administrator explained that he did not notify the Department of Health (DOH) of the use of paper plates because he did not consider it an interruption of resident services. The Administrator stated that the Boiler project was planned and residents were informed well in advance that paper plates would be used for meal times. The Administrator also stated that there was no change to the menu during this time and the only change in the meals was the use of the paper plates.

2. Review of facility fire drill records on 5/3/11 revealed a Fire Drill was conducted on 2/23/11 as a result of a Laundry Barrel Fire in the Laundry Department Room. Interview with the Administrator on 5/5/11 at approximately 10:22 AM revealed the fire was isolated to a barrel in the Laundry Room. The Administrator explained that the fire alarm was set off when a staff person discovered the fire and removed the smoking laundry barrel from the Laundry room to the outside of the building for extinguishment. Further interview with the Administrator at this same time revealed that the fire was extinguished by the staff person. The Administrator stated that the fire department responded to the alarm and after a brief check of the facility the "All Clear" was given. The Administrator stated he did not notify the Department of Health of the barrel fire because he did not consider it an interruption of resident services.

3. Review of facility fire drill records on 5/3/11 revealed a Fire Drill was conducted on 3/13/11 as a result of a rooftop air handler motor burning out. Further review of this report revealed smoke entered the Building at the Unit Three Nurse's station through the duct work. Upon the alarm sounding, a smoke damper activated and the air handler shut down.

Interview with the Administrator on 5/5/11 at approximately 10:25 AM revealed the fire department did respond to the alarm. After the Fire Department checked the facility with their infared guns and found no additional areas of fire concerns, the Fire Department gave the facility the "All Clear". The Administrator confirmed during this interview that he did not notify the Department of Health of the air handler motor burning out .

415.26(b)(13)

Based on observation and staff interview, the facility did not ensure that controlled drugs were stored in separately locked permanently affixed compartments in accordance with State and Federal regulations. Two (Units 2, 3) of four unit medication room refrigerators contained Schedule IV controlled drugs that were stored in locked boxes attached to removable shelves. The drugs were not stored in steel or metal boxes. This was a pattern with no actual harm with potential for minimal harm.

The findings are:

1. Observation of Unit 3 on 5/2/11 at 9:55 PM revealed the locked medication room refrigerator contained a plexiglass narcotic box, for the West Hall, West 3 Hall that was not secured to the refrigerator.

Observation of the contents of the box, in the presence of a Licensed Practical Nurse (LPN), revealed it contained an unopened box of one 30 milligram (mg) bottle of Lorazepam (Ativan-sedative/anti anxiety medication), 2 milligrams (mg) per milliliter (ml). The West Hall narcotic box was locked and was bolted to a removable shelf in the refrigerator.

During an interview on 5/2/11 at 10:00 PM, the Unit 3 Registered Nurse (RN) Nurse Manager (NM) stated she was surprised and did not know that the narcotic box was attached to a removable shelf in the medication refrigerator. Additionally, the NM stated she would see that the shelf was affixed to the refrigerator immediately.

2. Observation of the Unit 2 medication room on 5/2/11 at 6:30 PM revealed a medication refrigerator (a small dorm size unit) was locked and contained two shelves that contained locked plexiglass boxes that were bolted to the shelf. The first locked box contained a 30 milliliter (ml) bottle of oral Ativan and six vials of 2 milligrams (mg) size injectable Ativan. The second locked box contained three vials of 2 milligram size injectable doses of Ativan. Both shelves, with the boxes attached, were easily removed from the refrigerator.

Interview with the Registered Nurse (RN) Assistant Unit Manager on 5/3/11 at approximately 2:00 PM revealed the refrigerator shelf "has always been like that".

415.18(e)(1)(2)