Norwich Rehabilitation & Nursing Center

Based on observation, record review, and staff interviews conducted during the standard survey, it was determined the facility did not ensure an effective infection control program was in place to provide a sanitary environment and to prevent the development and transmission of disease and infection for 1 of 16 sampled residents (Resident #12). Specifically, the staff did not employ accepted infection control techniques for blood glucose (sugar level) monitoring as recommended by the Center for Disease Control's (CDC's) MMWR (Morbidity and Mortality Weekly Report) for Resident #12. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #12 was admitted to the facility with diagnoses of insulin dependent diabetes mellitus.

The May 1010 Medication Administration Record (MAR) documented the resident was to receive Accu-Cheks (test to monitor sugar levels in the blood)daily at noon.

On May 3, 2010 at 11:20 AM, the licensed practical nurse (LPN #1) was observed to take the glucometer (device to measure blood glucose levels) from the top of the medication cart and bring it into Resident #12's room. The LPN placed the glucometer on the arm of the resident's chair. She then obtained blood from the resident's finger, placed the glucometer on the arm of the chair, made sure the resident's finger stopped bleeding, removed the glucometer, and placed it on top of the medication cart, without cleaning or disinfecting it. The LPN then proceeded to continue her medication pass, and was not observed to use the glucometer again.

During an interview with LPN #1 on May 3, 2010 at 11:50 AM, LPN #1 was asked if she cleaned or disinfected the glucometer. the LPN said "no" and explained that sometimes she cleaned it with alcohol, but not after each resident.

Another interview was conducted with medication LPN #2 at noon on May 3, 2010. The surveyor asked LPN #2 if she cleaned the glucometer after each resident's use. LPN #2 said she should, but did not do it after each use. She stated that when she did clean it, she used an alcohol wipe.

The CDC's MMWR (Morbidity and Mortality Weekly Report) dated March 11, 2005, documented a shared glucometer must be cleaned and disinfected between residents.

The facility's Medical Equipment Cleaning and Sanitizing policy, reviewed/revised on January 1, 2010, documented for "Glucometers": clean and sanitize after each use. Wipe with an antimicrobial disinfectant wipe or bleach towelette, taking care to prevent fluid from entering any electronic parts or connectors."

In summary, the facility did not practice acceptable infection control practices when the glucometer was not cleaned and disinfected between residents.

10 NYCRR 415.19 (a)(1),(b)(2)

Based on observations, record reviews, and family and staff interviews conducted during the standard survey, it was determined the facility did not ensure the environment was free of accident hazards for 1 of 16 sampled residents (Resident #15), and for the residents on the third floor. Specifically, residents on the third floor were exposed to the unsafe placement of a radio and improperly secured hazardous chemicals. For Resident #15, the hazardous use of his lift chair was not assessed as a safety issue. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) During the orientation tour of the third floor nursing unit on May 3, 2010 at 11:30 AM, a surveyor entered the unit's centralized tub/shower/toilet room and observed a radio resting on top of the bathing tub's overhead reservoir tank. The radio was plugged into a nearby wall-mounted, 110-volt electrical receptacle. The cord was long enough that if the radio fell off the top of the tank, the radio could fall into a tub full of water during a resident's bath, presenting a severe shock hazard for the resident.

The placement of the radio in such a manner is considered an unsafe practice, as it is over-reliant on the assumption that the ground fault interrupter (GFI) was installed correctly and would always function properly when activated.

At 11:35 AM, the surveyor pointed out the unsafe location of the radio to the registered nurse (RN) Unit Manager who stated the top of the tub was not a good place for the radio.

In summary, the facility's unsafe placement of the radio presented electrical shock hazard to residents on the third floor.

2) During the orientation tour of the third floor on May 3, 2010 at 11:30 AM, and again on May 4, 2010 at 11:50 AM, a surveyor observed the doors were open to the storage cabinet in the third floor centralized tub/shower/toilet room. An unlocked padlock was observed hanging from one of the doors. Observed inside the cabinet were bottles of shampoo, hand cleansers, anti-microbial skin cleansers and sprays which are hazardous to residents if ingested or were exposed to their eyes.

At 11:55 AM on May 4, 2010, the surveyor showed the registered nurse (RN) Unit Manager was shown the open cabinet and was asked if the cabinet should be open. The Unit Manager stated the cabinet should be locked when not in use. He then closed the cabinet doors and locked them with the padlock.

In summary, the facility did not safeguard chemicals which are hazardous to the residents if ingested or exposed to their eyes.

3) Resident #15 had diagnoses including Alzheimer's disease, Parkinson's disease, and history of a fall-related fractured wrist and was admitted on February 17, 2010.

The comprehensive care plan (CCP), dated February 17, 2010, documented the resident was at high risk for falls related to impaired balance; history of falls in the past 6 months; and "cognitive impairment, but not totally dependent with mobility."

The re-admission history and physical examination, dated February 22, 2010, documented the resident was hospitalized for a right wrist fracture after he fell backward at home on February 11, 2010. The assessment included the problems of recurrent falls and gait instability, and a likely progression of dementia since his previous stay in the facility.

The admission Minimum Data Set (MDS) assessment, dated February 23, 2010, documented the resident had a short term memory deficit and moderate cognitive impairment; had periods of altered perception or awareness of surroundings; and was able to ambulate and transfer with extensive staff assistance.

The Physical Restraint Determination, completed by the registered nurse (RN) unit manager on March 3, 2010, documented the resident utilized a "belt," which he could remove "independently and consistently on command or request;" and the resident was "functionally capable of attempting to rise from the chair without device."

Nurses' progress notes, dated April 28, 2010 at 3:00 PM, documented the resident "attempted to get out of his chair, he had his lap belt off, and alarm was sounding. He had raised the recliner with the remote (control) to an upright position."

The facility's 24 hour report, dated April 28, 2010 did not document the resident had removed his lap belt and raised his recliner to an upright position on that day.

The resident's CCP for falls was updated on April 6, 2010, and included the intervention of a "lap belt in recliner when in recliner in room." The CCP did not evaluate adding new interventions, after the resident removed the seat belt on April 28, 2010, and raised his recliner to an upright position.

The current Direct Plan of Care, used by certified nurse aides (CNAs) to provide care, documented on March 29, 2010 that the resident was to be transferred to his recliner after dinner. On April 6, 2010, the Direct Plan of Care specified the lap belt was to be used when the resident was in the recliner. The Direct Plan of Care included no instructions to prevent the resident from standing up after using a remote control to elevate his recliner.

The resident was observed at 9:55 AM on May 4, 2010 to be alone in his room, seated in his recliner with an attached, alarmed seat belt. The resident was able to remove the seat belt at that time. The resident was also observed sitting in the recliner at 10:20 AM that day, and on the next day (May 5, 2010) at 11:25 AM.

At 5:50 PM on May 4, 2010, a surveyor interviewed the resident's family member regarding the resident's remote-controlled recliner. The family member stated the resident was capable of using the remote control to elevate his chair. "I put the remote in the pocket of the recliner where he can't reach it."

At 12:45 PM on May 5, 2010, the Director of Nursing (DON) was interviewed regarding the resident's remote-controlled recliner. The DON said the resident was able to raise the chair, stand up, and walk. She said she could not explain why the resident's CCP did not contain interventions related to the resident's risk to fall when he used the remote control to elevate the chair.

In summary, for a resident with a history of injury related to falls, the facility did not ensure care plan interventions to prevent the resident from falls when he utilized a remote control device to lift his recliner.

10 NYCRR 415.12 (h)(1)

Based on observations, record reviews, and staff interviews conducted during the standard survey, it was determined the services provided by the facility did not meet professional standards of quality for 5 of 24 sampled residents (Residents #5, 11, 13, 14, and 15). Specifically, licensed practical nurses (LPNs) performed assessments of Residents #5, 11, 13, 14, and 15 after their falls. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Review of the facility policy, "Fall Occurrence," dated January 22, 2010, revealed it documented that after a resident fall, a "licensed nurse" will "evaluate the resident for injury and arrange for necessary first aide and/or medical treatment." The policy did not specify the resident was to be assessed by an RN, according to professional standards of practice.

1) Resident #15 had diagnoses including Parkinson's disease, Alzheimer's disease, and depression.

The comprehensive care plan (CCP), dated February 17, 2010, documented the resident had a history of falls in the past 6 months; his balance was impaired; and he was not totally dependent with mobility. Interventions included use of a walker, a mobility alarm on his left ankle, and a lap belt while in his wheelchair. The resident was to walk to and from the dining room, and was to sit in a recliner in his room after dinner. The CCP was updated on April 6, 2010 to include the use of a lap belt in the resident's recliner.

The Admission Minimum Data Set (MDS) assessment, dated February 23, 2010, documented the resident had short term memory loss; moderate cognitive impairment; required extensive assistance for activities of daily living (ADLs); fell in the past 30-180 days; and had a fracture in the last 6 months.

A nurses' note, written by a licensed practical nurse (LPN) on February 27, 2010, documented that at 8:42 PM that evening, the resident leaned forward in his wheelchair, rolled to the floor onto his knees, onto his right hip and right side. The note documented the resident was not injured, and using a Hoyer (mechanical) lift, staff put him in his wheelchair, and then transferred him to his bed. The note documented the Director of Nursing (DON) was notified, as she was the on-call registered nurse (RN).

The Incident/Accident/Quality Assurance Document documented that on February 27, 2010, the resident fell at 8:42 PM; the DON was notified at 8:55 PM. The report did not document that the resident was assessed by an RN.

The DON was interviewed at 12:20 PM on May 5, 2010 about the assessment performed on the resident following his fall on February 27, 2010. The DON stated the LPN called her after the resident fell on February 27, 2010, and the DON assessed the resident via the telephone. The DON did not explain how she could assess the resident without visualizing or examining him.

A nurses' note, written by an LPN on April 6, 2010, documented at 5:20 AM that morning, the resident was found on the floor in front of his recliner, lying on his right side. The note documented the resident's range of motion (related to his extremities) was normal, and he was "Hoyered to bed. On-call RN notified."

The Incident/Accident/Quality Assurance Document documented on April 6, 2010, the resident fell at 5:20 AM; the LPN supervisor was notified at 5:30 AM. The report did not document that the resident was assessed by an RN.

A late entry nurses' note, written by the RN Unit manager on April 7, 2010, documented that following the resident's fall on April 6, 2010, the resident was alert, confused, neurologically grossly intact, and had no injury or signs and symptoms of pain.

At 12:45 PM on May 5, 2010, the RN Unit Manager stated he did not assess the resident after he fell on April 6, 2010. He stated he wrote the late entry note on April 7, 2010 without assessing the resident.

During an interview with the DON, Assistant DON, and RN Unit manager at 12:50 PM on May 5, 2010, they all stated they were not called by the LPN after the resident fell on April 6, 2010.

At 12:20 PM on May 5, 2010, a surveyor interviewed the DON about the assessment performed on the resident following his fall on April 6, 2010. The DON stated the medical record contained no documented RN resident assessment. When asked if she would expect an RN to physically assess a resident after a fall, the DON stated an RN should discuss the resident's condition with the LPN via telephone, and give verbal permission before the resident was moved.

A nurses' note, written by an LPN at 3:00 PM on April 18, 2010, documented the resident was found on the floor on his back in the doorway to his room (time not documented). The note documented there was "no visible injury seen. Resident combative with physical exam. Neuro(logical) check discontinued related to increased combativeness...resident yelling out with palpation of neck, head, and lumbar region." The note documented the nursing supervisor and on-call RN were notified, and the resident was taken to the hospital by ambulance at 1:00 PM.

The Incident/Accident/Quality Assurance Document documented on April 18, 2010, the resident was found on the floor at 12:30 PM; the LPN supervisor was notified at the same time. The report documented the resident complained of pain "everywhere," and had a mental status change, as he was not usually combative. The report did not document that the resident was assessed by an RN.

At 12:40 PM on May 5, 2010, a surveyor interviewed the DON and the RN who was on-call when the resident fell on April 18, 2010. The DON stated the LPN should not have performed a physical examination on the resident. The RN stated she did a "quick head to toe assessment" of the resident via telephone, and told the LPN to call an ambulance. The DON did not explain how she could assess the resident without visualizing or examining him.

In summary, the facility did not ensure professional standards of practice were followed when the resident experienced multiple falls, as:
- the resident was not physically assessed for injury by an RN after each fall;
- an LPN examined the resident on 1 occasion, which is outside the scope of practice for an LPN;
- an RN documented a resident assessment without performing a physical assessment.

2) Resident #5 had diagnoses including osteoarthritis, congestive heart failure, glaucoma, and dementia.

The Minimum Data Set (MDS) assessment dated March 12, 2010, documented the resident had memory deficits, was cognitively impaired to a moderate degree, was usually understood by others, required limited assistance with transfer and ambulation and extensive assistance with bed mobility, dressing, toileting, and personal hygiene.

The current Plan of Care, re-written on April 28, 2010, documented the resident was at risk for falls and serious injury due to a history of falls in the past 6 months, her cognitive impairment, diagnosis of osteoarthritis, and impaired vision. Interventions included using a walker with reminders when ambulating, wearing non-skid socks without shoes, and using a mobility alarm while in bed.

An "Incident/Accident Quality Assurance Document" written by the licensed practical nurse (LPN) and dated April 28, 2010 at 1:10 AM, and LPN progress notes dated April 28, 2010 at 1:30 AM, both specified that after a noise was heard from the hall, the resident was found in her room, sitting on the floor beside the bathroom door. The resident said she lost her balance and lowered herself to the floor. Her ROM was within normal limits. The registered nurse (RN) supervisor was called. There was no apparent injury noted and the resident tried to get herself up. The LPN progress note specified the resident refused the Hoyer lift (mechanical device used for transfer), and was assisted off the floor. The resident ambulated to her bed and said she had no pain. She was checked for bumps and bruises with none found. The resident was assisted back in bed and her mobility alarm was attached. The progress note documented the resident would be monitored for mobility or marks on her skin resulting from the fall. There was no documented evidence in the medical record an RN assessed the resident following her fall.

An interdisciplinary progress record written by an LPN, dated April 28, 2010 at 3:20 PM, documented the resident had no injury noted from her earlier fall. The resident was "ambulating slowly", refused breakfast, and ate lunch in the dining room. There was no documented evidence an RN assessed the resident following her fall during the night.

On May 5, 2010, the Director of Nursing (DON) provided the surveyor with the job description for LPNs (dated September 2000). The job description documented "care must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility as required by the Nurse Supervisor, Unit Manager and Director of Nursing to ensure the highest degree of quality care is maintained at all times." The job description did not document that LPNs could perform assessments on residents following their fall.

In summary, the facility:
- did not ensure the resident was assessed by an RN following a fall.
- did not ensure LPNs performed duties within their scope of practice.

3) Resident #11 was admitted to the facility with diagnoses including status post right hip hemiarthroplasty (hip replacement) performed on March 29, 2010.

The Minimum Data Set (MDS) assessment dated April 14, 2010 documented the resident had some problems with short time memory, but was independent in decision making. He needed extensive assistance for transfer, dressing, and personal hygiene.

The current Plan of Care dated April 6, 2010 documented the resident was at risk for falls related to a history of falls in the past 6 months, and due to his impaired gait and balance. The CCP specified the resident ambulated with a walker and required extensive assistance.

The "Incident/Accident Quality Assurance Document" dated April 13, 2010 documented at 5:20 AM, the resident was found on the floor on the right side of the bed with his head resting on the bedside table. The LPN supervisor assessed the resident and found neurological checks to be within normal limits. The resident's range of motion ROM was found to be within normal limits. The LPN supervisor documented the registered nurse (RN) was notified.

A nursing note written by the LPN and dated April 13, 2010 at 8:15 AM, documented the resident was found at 5:20 AM on the floor on the side of the bed, lying on his back. No pain or discomfort was noted. The resident had range of motion in all extremities. The note documented the RN on call was notified.

During an interview with the RN Unit Manager on May 5, 2010 at 10:10 AM, she was asked about getting called during the night after a resident fell. The RN Unit Manager said when she was called, she would ask for all the details including what the resident was doing prior to the fall, did they need to use the bathroom, and if there were were any visible injuries. The RN manager said she would then ask for a full set of vital signs to be taken, including neurological checks. If the RN Unit Manger felt comfortable with the information obtained from the LPN, then she would instruct the LPN to have the resident "Hoyered" back to bed. The RN Unit Manager said the resident was not moved until the nursing staff talked to the RN on call.

On May 5, 2010 at 11 AM, a telephone interview was conducted with the LPN who worked as the evening supervisor on April 13, 2010. The LPN said the protocol was that LPNs could not assess residents. The LPN said she gathered information and contacted the RN on call. The surveyor asked the LPN what information was gathered. The LPN said she would see if the resident had pain, and if the resident could move. If the resident said "yes" to those questions, then they were asked to move their extremities. The LPN checked for bruises and took vital signs. The LPN said that information was all given to the RN on call. If the RN "OK'd" it, staff would get the resident up off the floor. The LPN was asked if she was the night supervisor. She said she was, "but not by choice."

In summary, the facility:
- did not ensure the resident was assessed by an RN following a fall.
- did not ensure LPNs performed duties within their scope of practice.

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

Based on observations, record review, and staff interviews conducted during the standard survey, it was determined the facility did not provide the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents reviewed with pressure ulcers (Resident #2). Specifically, staff were unaware of the existence of 3 new pressure ulcers on Resident #2's feet and 1 on her sacrum, until observed during survey. The care plan intervention for Resident #2 to be free of shoes was not followed. Staff did not evaluate, in a timely manner, the relationship of the resident's bed cradle and dressing wrap to the development of new pressure ulcers. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE MARCH 12, 2009 SURVEY.

Findings include:

Resident #2 had diagnoses including congestive heart failure (CHF) and history of stroke with left-sided hemiplegia (weakness).

The Minimum Data Set (MDS) assessment for a significant change in status, dated January 31, 2010, documented the resident had a short term memory deficit; mild cognitive impairment; required extensive assistance for bed mobility and activities of daily living (ADLs); was non-ambulatory; had a Stage I pressure ulcer and history of resolved pressure ulcer(s); had foot problems; and received preventive or protective foot care.

Review of the resident's Wound Progress notes revealed:
- the onset of a Stage I pressure ulcer on the resident's right third toe was January 6, 2010, and was described as "healed" on January 13, 2010.
- the onset of a Stage I pressure ulcer on the resident's right second toe was January 13, 2010, and was described as "healed" on February 10, 2010.

Physician's orders, dated April 26, 2010, documented the resident was to have weekly full body skin checks, an Unna Boot (compression dressing) to the right foot and ankle, cover with Kerlix (gauze wrap) and ace wrap (elastic bandage), and change Monday, Wednesday, and Fridays.

The comprehensive care plan (CCP), dated May 2010, documented the resident was at high risk for developing pressure ulcers related to risk factors of impaired mobility, exposure of skin to moisture from incontinence, and CHF. Interventions included utilization of non-skid socks without shoes to allow the resident to feel the floor and compensate for decreased depth perception (related to fall risk), and a pink pillow to off-load pressure. The CCP did not specify the resident was to wear shoes, and did not include the intervention of a bed cradle.

The resident was observed in the dining room, wearing shoes and socks at 5:50 PM on May 3, 2010.

At 9:45 AM on May 4, 2010, the resident's bed was observed to have a metal bed cradle (used to keep bedding off the resident's feet) attached to the foot of her bed.

At 9:45 AM on Wednesday, May 5, 2010, a surveyor observed the resident's skin during the right ankle dressing change by the Assistant Director of Nursing (ADON), in the presence of the registered nurse (RN) Unit Manager. The resident was observed to have 4 new open skin areas at that time:
- right great toe: 0.3 centimeter (cm) x 0.3 cm, covered with hard, dark material;
- end of right great toe: 0.4 cm x 0.4 cm, with dark blister;
- left lateral foot: 0.5 cm x 0.4 cm, with hard, black material;
- left sacrum: 0.1 cm x 0.1 cm open area.

When interviewed during the above observation (the morning of May 5, 2010), the ADON stated the new areas of skin breakdown on the resident's right toe "might be related to" pressure from the Unna Boot dressing, and said the area on the resident's left foot might be related to pressure from her shoes, or from striking the bed cradle. The ADON and RN Unit Manager said they were not notified about the 4 new open skin areas. The ADON stated licensed practical nurses (LPNs) documented weekly resident skin checks.

Review of the facility's policy, "Pressure Ulcer Prevention", dated March 2008, revealed certified nurse aides (CNAs) were to inspect residents' skin condition at least twice daily, and report any abnormalities to the charge nurse. The policy documented nursing staff was responsible for monitoring for "blisters, redness, etc. on feet from improper fit of shoes."

Review of the "New Skin Problem Detail Report" for the 3 months prior to survey (February 2010 to May 5, 2010) did not document the discovery of new open skin areas during that time period.

Review of the resident's interdisciplinary progress notes, from April 1 to May 5, 2010, revealed no documentation that staff discovered or assessed the resident's 4 new open skin areas found during the skin observation on May 5, 2010 at (;45 AM.

In summary, for a resident with a history of pressure ulcers and at high risk to develop skin breakdown, the facility did not provide services to ensure the resident did not develop new pressure ulcers as:
- staff were unaware of the existence of 3 new pressure ulcers on the resident's feet and 1 on her sacrum, until a skin observation made during survey;
- care planning interventions for the resident to be free of shoes were not followed; and
- staff did not evaluate, in a timely manner, the relationship of the resident's bed cradle and dressing wrap to the development of new pressure ulcers.

10 NYCRR 415.12 (c)(2)

Based on observations, record review, and family and staff interviews conducted during the standard survey, it was determined the facility did not ensure 1 of 2 residents reviewed for restraint concerns (Resident #15) was free from physical restraints not required to treat his medical symptoms. Specifically, for Resident #15, the facility did not provide a physician's order for the restraints used; did not ensure a care plan was developed for seat belts to be used as restraints; did not develop a plan to reduce or eliminate restraints and to minimize the risk of injury; and did not provide direct care staff with directives for release of the restraints. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #15 was originally admitted on November 11, 2009, and re-admitted on February 17, 2010. The resident's diagnoses included Alzheimer's disease, Parkinson's disease, and history of fractured wrist from a fall in February 2010.

A psychological consultation, dated November 15, 2009, documented the resident was disoriented; did not realize he was in a health care facility; and his reality testing and judgment were "grossly impaired."

The comprehensive care plan (CCP), initiated upon his readmission and dated February 17, 2010, documented the resident was at high risk for falls related to impaired balance; history of falls in the past 6 months; and "cognitive impairment, but not totally dependent with mobility." Interventions included a "lap belt in wheel chair." The CCP did not document the lap belt was a restraint, and did not include directions when it was to be used and/or released.

The re-admission history and physical examination, dated February 22, 2010, documented the resident was hospitalized for a right wrist fracture, after he fell backward at home on February 11, 2010. The assessment included the resident's recurrent falls and gait instability, and a "likely progression of dementia" since his previous stay in the facility. The plan documented the resident required no restraints.

The admission Minimum Data Set (MDS) assessment, dated February 23, 2010, documented the resident had a short term memory deficit and moderate cognitive impairment; had periods of altered perception or awareness of surroundings; was able to ambulate and transfer with extensive staff assistance; and had no physical restraints.

The Brief Interview for Mental Status, completed by the Director of Social Work on February 25, 2010, documented the resident was not oriented to the year and day of the week, and he could not recall 2 of 3 words presented during testing.

The Physical Restraint Determination, completed by the registered nurse (RN) Unit Manager on March 3, 2010, documented the resident utilized a "belt," which he could remove "independently and consistently on command or request;" specified the resident was "functionally capable of attempting to rise from the chair without device;" and the "belt" was not a restraint.

Medical Service Progress notes, written by the nurse practitioner (NP) on March 17, 2010, and by the physician on April 12, 2010, each documented the resident did not have orders for physical restraints.

The resident's current Direct Plan of Care, used by certified nurse aides (CNAs) to provide care, contained the following updates:
- on March 2, 2010: lap belt at all times; hook up belt alarm on hook on dresser.
- on March 29, 2010: the resident was to be transferred to his recliner after dinner. - on April 6, 2010: lap belt when in recliner.
The Direct Plan of Care included no directives when to release the lap belts.

The resident's CCP for falls was updated on April 6, 2010, to include the intervention of a "lap belt in recliner when in recliner in room." The CCP did not document the lap belt was a restraint; did not include directives for its use and/or when to release the belt; did not address new interventions after the resident slid under the recliner's seat belt, and after he removed the seat belt and raised the recliner to an upright position.

A work order, dated April 6, 2010, documented a request for a lap belt to be attached to the recliner in the resident's room.

The 60-day routine physician's orders, dated April 12, 2010, documented the resident was to change his posture slowly to avoid low blood pressure. The physician's orders did not include an order for seat belt restraints in the resident's wheel chair and/or recliner.

Nurses' progress notes between the dates of April 2, 2010 and April 28, 2010, documented the following:
- on April 2, 2010 at 10:45 PM, the resident moved himself to the foot of his recliner and was found with his feet on the floor.
- on April 5, 2010 at 5:20 AM, the resident was found on the floor in front of his recliner.
- on April 12, 2010 at 11:25 PM, the resident was in his recliner, continuing to remove his lap belt. "Once found resident standing by recliner".
- on April 13, 2010 at 11:30 PM, "resident slid out of recliner under lap alarm".
- on April 28, 2010 at 3:00 PM, the resident "attempted to get out of his chair, he had his lap belt off, and alarm was sounding. He had raised the recliner with the remote (control) to an upright position."

The facility's 24-hour reports during the month of April 2010, documented the following information regarding the above events:
- April 2: no information documented.
- April 6: the resident fell out of his chair (on April 5). The report did not document the conditions/factors at the time of the resident's fall.
- April 13: the resident fell on the night shift on April 12. The report did not document the resident had slid out of the recliner under the lap belt.
- April 28: the report did not document that the resident removed his lap belt and raised his recliner to an upright position.

At 9:55 AM on May 4, 2010, a surveyor observed the resident alone in his room, seated in a recliner, with the foot rest elevated. A seat belt, bolted to the recliner, was attached across the resident's lap. When the resident was asked why the seat belt was attached, he said, "It's some kind of law." When he was asked if he could remove the belt, the resident unclipped it, and an alarm sounded. The licensed practical nurse (LPN) medication nurse, who was outside the resident's room at the time, came in an reattached the seat belt. When the LPN was asked why the resident had a seat belt attached to his recliner, the LPN stated, "He likes to get out of the chair." At 10:20 AM, the resident was observed to remain alone in his room, in the recliner with the seat belt attached.

On May 4, 2010, the resident was observed in his wheel chair with an attached seatbelt on the following occasions:
- between 11:00 and 11:20 AM, in the dining room, during a group music activity conducted by 2 activity aides;
- 12:15 PM, in the dining room, eating lunch;
- 5:45 PM, in the dining room, eating supper.

At 5:50 PM on May 4, 2010, a surveyor interviewed the resident's family member regarding the seat belt attached to the resident's recliner. When the family member was asked if she was aware the resident fell to the floor after sliding under the seat belt, she replied, "Yes. That's why they tightened it up."

The resident was observed alone in his room at 11:25 PM on May 5, 2010, asleep in his recliner and the seat belt was attached.

The facility policy, Physical Restraints, dated February 2, 2004, documented residents were to be free from any physical restraint, except as required to treat residents' medical symptoms. Examples of physical restraints were the use of devices in conjunction with a chair, such as belts, that the resident could not remove easily, and which prevented the resident from rising. The procedure for use of physical restraints included the re-evaluation of the restraint at the time of any incident or accident involving the restraint.

At 12:25 PM on May 4, 2010, a surveyor interviewed the RN Unit Manager regarding the resident's seat belts. The RN stated the resident probably could have his seat belt released when he was supervised in the dining room. The RN Manager stated the seat belts in the resident's recliner and wheelchair were not care planned as restraints, because the resident could remove them. The RN stated he was unaware the resident did not know the purpose of the seat belts.

During an interview with the resident's assigned CNA at 12:50 PM on May 4, 2010, she stated the resident was able to get out of his wheelchair and recliner. She stated she was given no instructions if/when to release the seat belts, including during meals and activities.

At 12:45 PM on May 5, 2010, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed about the use of seat belts in the resident's recliner and wheel chair. They stated they did not believe it was necessary to care plan seat belts as restraints because the resident was able to release them.

In summary, for a cognitively impaired resident with a history of falls, one of which involved sliding under a seat belt, the facility:
- did not ensure the resident was free from physical restraints not required to treat his medical symptoms;
- did not provide a physician's order for the restraints;
- did not ensure a care plan was developed for seat belts to be used as restraints, with a plan to reduce or eliminate them and to minimize the risk of injury; and
- did not provide direct care staff with directives regarding the release of the restraints.

10 NYCRR 415.4 (a)(2)(iv),(3)(i-iii)

Based on observations and interviews with family and staff conducted during the standard survey, it was determined the facility did not provide a clean, comfortable, and homelike environment for residents. Specifically, the facility did not provide an environment that was free of persistent offensive odors. This affected 1 sampled resident (Resident #2) and 1 resident outside the survey sample (Resident #17). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

During the initial unit tour at 12:10 AM on May 3, 2010, a surveyor detected a strong urine odor in the room of Residents #2 and 17. An air purifier was observed operating in the room. The odor was detected in the same room at 9:45 AM on May 4, 2010.

At 11:20 AM on May 4, 2010, a surveyor interviewed 2 family members of Resident #2. They stated they visited the resident twice weekly, and noticed an odor in the resident's room "a few weeks ago." They said they brought it to the attention of staff, and the odor has persisted.

At 5:47 PM on May 4, 2010, 2 surveyors inspected the upholstered chair of Resident #17. Upon lifting a cloth pad and gel cushion from the chair, a strong urine odor was detected on the seat of the chair.

At 10:30 AM on May 5, 2010, a surveyor interviewed the Director of Maintenance about the air purifier running in the residents' room where the urine odor was identified. He stated the purpose of the machine was to remove odors, and the facility moved it from room to room as needed.

At 10:40 AM on May 5, 2010, a surveyor interviewed the registered nurse (RN) Unit Manager and the Assistant Director of Nursing (ADON) about the urine odor in the room. They stated they were aware the source of the odor was the chair owned by 1 of the residents, and the facility had cleaned it in the past. At 1:20 PM, the RN Unit Manager said he and the ADON determined a urine odor was coming from the chair. He said the resident's gel cushion was replaced, and the facility planned to have the chair cleaned and put on a regular cleaning schedule.

In summary, the facility did not provide an environment free of persistent offensive odors.

10 NYCRR 415.5 (h)(1)