Norwich Rehabilitation & Nursing Center

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure food was palatable and served at an appropriate temperature at 1 of 2 meals observed (supper on April 4, 2011) which included cold entrees. Specifically, the cold holding system implemented for the supper meal on April 4, 2011 was not effective at maintaining cold food cold, including egg salad sandwiches, puree egg salad sandwiches, and mechanical soft cucumber salad.
Findings include:

The trayline for the supper meal was observed in the kitchen on April 4, 2011 between 5:15 PM and 6 PM. The first choice entree was an egg salad sandwich served with cucumber salad. A surveyor observed the steam table included 3 sections; one section included soup, one section (the middle) included the egg salad sandwiches, and the cucumber salad was in one section. The surface of the steam table near the soup felt hot to touch. The puree egg salad sandwiches were in a pan on top of the steam table without any cold food support (not iced or refrigerated).

A surveyor determined food temperatures from the serving line between 5:50 PM and 5:55 PM at the end of the meal service. Temperatures determined were as follows (in degrees F):
- regular egg salad sandwiches 69 degrees, 70 degrees, 70 degrees, and 72 degrees;
- puree egg salad sandwiches were 74 degrees and 78 degrees;
- mechanical soft cucumber salad was 61 degrees.
When the regular egg salad sandwiches were picked up (with gloved hands) the bread felt dried out. Both the regular and puree egg salad sandwiches tasted warm.

When the server was interviewed on April 5, 2011 between 5:50 PM and 6 PM, she stated the two heating units under the sandwiches and cucumber salad were not turned on. The server stated there was ice in the pan under the sandwiches when the line was set up.

A surveyor observed the section of the steam table the soup was held in was turned on; the other 2 sections were not turned on. When the pan holding the sandwiches was pulled out of the steam table, the pan under the sandwiches contained warm water (the water temperature was over 100 degrees F).

An anonymous resident in the Unit 3 dining room was overheard telling her tablemates the bread in her egg salad sandwich was dried out between 6:10 PM and 6:20 PM. The resident was observed eating her supper between 6:10 PM and 6:55 PM. None of the egg salad sandwich was consumed by 6:55 PM.

Per the Trayline/Temperature Control Record for April 5, 2011, food temperatures for supper before service were:
- egg salad sandwiches 40 degrees F;
- puree egg salad sandwiches 38 degrees F;
- mechanical soft cucumber salad 38 degrees F.

When the Food Service Director was interviewed April 7, 2011 at 1 PM, she stated she was not aware there was a problem with the cold food temperatures, and she had not received resident complaints about sandwiches.

In summary, the cold holding system did not maintain cold food at an acceptable temperature and some cold food items, regular egg salad sandwiches, puree egg salad sandwiches, and mechanical soft cucumber salad, were not palatable.

10NYCRR 415.14(d)(2)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 8 residents (Resident #1) reviewed with pressure ulcers received the necessary services to prevent the development of pressure ulcers. Specifically, the facility did not provide documented evidence the resident received weekly skin checks as planned; did not provide documented evidence the resident's feet were elevated on the pink pillows when in bed; and did not discover the pressure ulcers on the resident's heels until the CNA reported them, and they were assessed by the RN as unstageable.
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 MAY 5, 2010 SURVEY.

Findings include:

Resident #1 had diagnoses of senile dementia, hypertension, osteoporosis and urinary incontinence.

The comprehensive care plan (CCP) for pressure ulcer prevention, updated on June 15, 2010, documented the the resident was at low risk for developing pressure ulcers. The planned interventions were to follow the pressure ulcer prevention standard of care. The Pressure Ulcer Prevention Standard of Care included the following:
- the certified nurse assistant (CNA) inspect skin condition at least twice daily with AM and bedtime (hs) care;
- the LPN evaluates skin condition weekly and document findings;
- monitor for blisters, redness, "etcetera" on feet from improper fit of shoes; and,
- elevate heels off mattress when in bed, using pillow under legs.

A physician progress note dated March 18, 2011 documented the resident had been hospitalized on March 14, 2011 and was readmitted to the facility on March 18, 2011.

The physician's Readmission History and Physical dated March 18, 2011 documented the resident's extremities had "no cyanosis (blue discoloration from lack of oxygen), clubbing (changes to the nail bed from poor circulation) or edema (swelling)". The physician documented the resident had a Venous Doppler (ultrasound) study of the left leg on March 16, 2011 which was negative for blood clots.

The Nursing Assessment and History for re-admission by the registered nurse (RN) unit manager, dated March 18, 2011, documented the resident was at risk for pressure ulcers, and had 'dry flaky' skin on both heels.

The physician's order dated March 18, 2011 instructed staff to apply A&D ointment to both heels twice a day.

The March, 2011 treatment administration record (TAR) documented the resident was to receive weekly full body skin checks on the 3 PM to 11 PM shift, on Thursday's. The weekly full body skin check was not signed (left blank) after the resident was readmitted to the facility on March 18, 2011.

The certified nurse assistant (CNA) Skin Check Detail Report dated March 19 through March 23, 2011 had 15 entries which documented no new skin problem had been seen by the CNA.

A nurse practitioner (NP) progress note dated March 23, 2011, documented the resident had 3 blisters on the left heel, one blister had broken open and had drained yellow fluid on a gauze, the 2 others each measure approximately 1 x 1 centimeters (cm). There was another blister which measured 6 x 6 cm on top of the resident's left foot. The NP diagnosed the resident with a left foot "infection" and edema of the left leg and foot. The NP ordered a single dose of Lasix (a diuretic) 20 milligrams (mg) by mouth to treat the resident's left leg edema and Keflex (an antibiotic) 500 mg each day for 5 days, to treat the resident's left foot infection.

On March 23, 2011, the physician ordered an ace (elastic) bandage be applied to the resident's left ankle to treat swelling.

The March 23, 2011 TAR weekly skin check was not signed and there was no documented evidence it had been performed.

The certified nurse assistant (CNA) Skin Check Detail Report dated March 24 through March 25, 2011 had 6 entries which documented no new skin problem had been seen by the CNA.

The Minimum Data Set (MDS) assessment, dated March 25, 2011 documented the resident had moderately impaired cognitive level, needed extensive assistance of 2 persons for moving in bed and was at risk of developing pressure ulcers and had none.

The CNA Skin Check Detail Report dated March 26 through March 28, 2011 had 9 entries which documented no new skin problem had been seen by the CNA.

A physician progress note dated March 28, 2011 documented he had examined the resident. The 3 blisters on the left heel and the blister on the top of the left foot were resolved.

The CNA Skin Check Detail Report dated March 29 through March 30, 2011, had 5 entries which documented no new skin problem had been seen by the CNA.

The CNA Skin Check Detail Report dated March 30, 2011 at 10:25 AM documented the resident had a new skin problem that was reported to the nurse and the area of concern was "both heels open."

A Wound Progress Note - Wound Assessment dated March 30, 2011 documented both of the resident's heels had unstageable pressure ulcers with eschar (thick, leathery, necrotic, tissue). The right heel pressure ulcer measured 2 cm x 1.5 cm and the left heel pressure ulcer measured 5 cm x 4 cm; this was signed by the RN unit manager and the RN director of nursing.

On March 30, 2011 the CCP for Chronic Wound-Pressure Ulcer was added and included the following interventions:
- follow Pressure Ulcer Prevention and Pressure Ulcer Treatment Standards of Care;
- interdisciplinary skin care team visits weekly;
- topical therapy/dressing: refer to TAR/physician's orders; and,
- footwear modifications: Allevyn heels, blue booties when out of bed, pink pillow when in bed.

The March 31, 2011 TAR weekly skin check was not signed and there was no documented evidence it had been performed.

On April 1, 2011, a physician progress note documented the resident had bilateral unstageable heel ulcers. The physician wrote orders for Allevyn heels (a cup-shaped foam dressing) to be worn inside socks at all times, blue booties (pressure relieving) to be worn when out of bed, skin prep (protective coating) applied to both heels daily and a pink pillow (pressure relieving device) to float heels when in bed.

On April 5, 2011 at 3:10 PM, the RN unit manager was interviewed regarding his assessment of the areas on the resident's heels as 'dry flaky' on the re-admission Nursing Assessment and History. The RN stated they were the same areas now identified as unstageable pressure ulcers. He further stated he didn't call the 'dry flaky' areas Stage I pressure ulcers when he first assessed them,"but maybe I should have."

On April 6, 2011 at 3:20 PM, the RN unit manager stated the wound care team consisted of himself, the RN director of nursing (DON) and a dietitian; wound care rounds were performed each week on wednesdays. He stated the resident was not seen on wound care rounds when she returned from the hospital because there were no identified areas of concern. The RN stated he felt the resident had the same level of pressure ulcer risk as prior to her hospitalization, so he continued the same prevention which consisted of using the pink pillow in bed to reduce pressure on the heels.

On April 6, 2011 at 10:55 AM, the resident's heels were observed during a wound care treatment. The resident was seated in a wheelchair in her room, the licensed practical nurse (LPN) removed blue booties, socks and Allevyn heels from both feet. The resident's left heel pressure ulcer measured approximately 5 cm x 4 cm with dark pink tissue in the wound bed, the surrounding tissue was intact and there was no drainage noted. The resident's right heel pressure ulcer appeared equal in size to the left with thickened dark brown/black tissue in the wound bed. There was no drainage noted and the surrounding tissue was intact.

The April, 2011 TAR documented the resident was to receive weekly full body skin checks on the 7 AM to 3 PM shift, on Wednesday's. The weekly skin check dated April 6, 2011 was not signed and there was no evidence that it had been performed.

In an interview on April 7, 2011 at 9:00 AM, the RN unit manager stated the resident was not seen during wound rounds that week, and offered no explanation. He said the pink pillow used for floating the resident's heels was written on the CNA Direct Plan of Care and was not signed for until it was written as a physician order on April 1, 2011.

On April 7, 2011 at 10:20 AM, the RN Unit Manager was interviewed regarding the weekly skin check order on the TAR, which was not signed as being performed after the resident returned to the facility from the hospital on March 18, 2011, until the present date. He stated that if it was not signed, it was not done.

During an interview on April 7, 2011 at 9:50 AM, the RN DON stated the pink pillows were a standard of care and there was no CNA documented accountability for their use unless it was written as a physician's order. The DON stated if the resident refused weekly skin checks, the refusal should be documented.

On April 7, 2011 at 1:20 PM, the CNA (assigned to care for the resident) was interviewed and stated, "The pink pillow has always been on her bed, but if she moves during the night you can't be sure her heels are still on it. There's no guarantee her heels are up on the pillow all the time."

In summary, the facility did not:
- provide documented evidence the resident received weekly skin checks as planned;
- provide documented evidence the resident's feet were elevated on the pink pillows when in bed; and
- discover the pressure ulcers on the resident's heels until the CNA reported them, and they were assessed by the RN as unstageable.

10NYCRR 415.12(c)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure fire drills were conducted quarterly on one of three shifts, the day shift (6:30 AM to 2:30 PM), in the last 3 quarters of 2010 (April through December 2010), and that all fire drills simulated emergency conditions. Specifically, there were no day shift drills conducted between April and December 2010, required drills conducted at night did not routinely simulate emergency conditions, and the alarm was not rung for all required fire drills conducted between 6 AM and 9 PM. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

When the Director of Nursing was interviewed on April 5, 2011 at 5:30 PM, he stated the nursing shifts were:
- 6:30 AM to 2:30 PM (day shift);
- 2:30 PM to 10:30 PM (evening shift);
- 10:30 PM to 7 AM (night shift).
He stated all, or nearly all of the nursing staff, including RN (registered nurse) Unit Managers, LPNs (licensed practical nurses), and CNAs (certified nurse aides) work per this schedule.

The Fire Drill Log 2010, updated April 11, 2011, documented fire drills in the last 12 months, as follows:
Second quarter (April through June 2010):
- April 26 at 5:20 AM (night shift) and April 29 at 4 PM (evening shift);
- May 22 at 5:35 PM (evening shift);
- June 21 at 6 AM (night shift).
There was no documented day shift fire drill in the second quarter of 2010.
Third quarter (July through August 2010):
- July 9 at 5:15 AM (night shift);
- August 13 at 4:08 PM (evening shift);
- September 18 at 5:45 AM (night shift).
There was no documented day shift fire drill in the third quarter of 2010.
Fourth quarter (October through December 2010):
- October 7 at 3 AM (night shift);
- November 14 at 7:20 PM (evening shift);
- December 23 at 4:30 AM (night shift)
First quarter (January through March 2011):
- January 24 at 8:29 AM (day shift)
- February 17 at 5:35 AM (night shift)
- March 27 at 9:15 PM (evening shift).

Per the Fire Drill/Event Evaluation Forms:
- the fire alarm was not rung for the fire drill conducted on June 21, 2010 at 6 AM;
- the fire drill was not rung for the fire drill conducted on November 14, 2010 at 7:20 PM.
- the fire drill conducted on June 21, 2010 at 6 AM in the kitchen, staff were questioned about their response to a specific fire scenario in the kitchen for the drill, and responded to the questions of the individual conducting the drill. There was no documented evidence this drill was a rehearsal of the fire plan.

There was no documented evidence day shift fire drills were conducted in the second, third, and fourth quarters of 2010.

When the maintenance director was interviewed on April 7, 2011 between 11:15 AM and 11:45 AM, he stated he considered early morning hours (for example around 6 AM) to be the day shift. He stated for drills during the night, the facility did not always use the paging system during a fire drill. He felt the paging system was loud and disruptive. He stated that during some of the drills held at night, he discussed staff's response to a fire with individual staff, and staff did not necessarily rehearse steps in the fire plan (for example, closing corridor doors and simulation of pulling the alarm).

In summary, facility fire drills in the last 12 months:
- were not held quarterly on each shift;
- did not always simulate emergency conditions to the extent possible; and
- did not always include ringing the alarm for required drills conducted between 6 AM and 9 PM.

10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the post indicator valve (main outside control valve/control to turn off the sprinkler system water supply) for the building sprinkler system was electrically supervised (electrical supervision notifies the facility in the event the sprinkler system water is turned off). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

When the post indicator valve was observed on April 9, 2011 at 9 AM, the valve was locked and did not have electric supervision.

When the Maintenance Director was interviewed on April 7, 2011 at 11:15 AM, he stated he was not aware supervision was required for the post indicator valve.

In summary, the post indicator valve was not electrically supervised as required.

10NYCRR 415.29(a)(1&2) , 711.2(a)(1)