Nys Veterans Home in Nyc

Based on observations, record reviews and resident and staff interviews, the facility did not ensure that residents participated in an ongoing program of activities in accordance with the comprehensive assessment to promote or enhance physical, cognitive, and emotional health. This was evident for two (2) of thirty (30) sampled residents. (Residents #4 and #24)

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1.) Resident #4 is an 87 year old admitted on 4/7/2010 with diagnoses that included Depression, Cerebrovascular Accident (CVA), Diabetes and Hypertension (HTN).

The Minimum Data Set (MDS) 2.0 Assessment dated 4/21/10 documented that total care is needed for this resident who has modified independence for cognition. The MDS documented that the resident participates in activities "some of the time."

On 6/23/10 a.m. during the initial tour and 6/25/10 at 3:30 p.m., the resident was observed in his bed covered with a sheet over his head. There was no television or radio by the resident's bedside. On 6/29/10 at 3:00 p.m., the resident was observed in the hallway facing the nursing station. On 6/30/10 at 9:15 a.m., the resident was observed in his bed sleeping with glasses on. There were no activities observed to be provided.

The Comprehensive Care Plan dated 4/22/2010 documented a goal for "Resident will continue to attend activities of choice within 90 days." The care plan further documented interventions: "Maintain positive manner when inviting resident to activities. Provide variety in activities based on resident's preferences. Include resident in group activities."

There was no documented evidence that resident was invited or participated in activities.

On 6/29/10 at 3:25 p.m., the activities leader was interviewed and stated that for residents that do not come out of there room she provides 1:1 activities. There was no documented evidence this was done.

2.) Resident #24 a 36 years old female admitted to the facility on 6/09/10 with diagnoses: new onset Seizures, Cerebrovascular Accident with Right Hemiparesis, Aphasia and Lupus Erythematosus.

The resident was observed and interviewed in her room on 6/30/10 at 10:00 a.m. She was alert, oriented to time, place and person. Ambulates independently around the perimeter of her room between her bed and closet. Her left side was observed with good range of motion. During this visit, she was observed arranging her numerous CDs (compact discs). Resident was asked about her days in the facility and how she spends her time, she stated - with some difficulty and at times pointing on the calendar: "There is nothing to do here. See I have my own CDs. All day I stay in the room."

The Minimum Data Set (MDS) dated 6/16/10 documented that the resident is independent with cognition with short and long term memory and needs assistance with some of her ADLS (Activities of Daily Living).

Review of the Comprehensive Care Plan for Activity reveals neither documented evidence of an assessment done on the resident nor was there an evidence that the resident has participated in any activities from 6/09/10 to 6/30/10.

During an interview with the Activities Director on 6/30/10 at 11:05 a.m. she stated, "I was to do it, do the interviews and assessment of the resident's interest and gather the things she will need but you know, every time I need the chart it is not available. I know I started it, I will follow it after I have done my group."

415.5(f)(1)

Based on observations, record review and resident and staff interviews, the facility did not ensure that a resident was assessed for activities. This was evident for one (1) of thirty (30) sampled residents. (Residents #4)

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1.) Resident #4 is an 87 year old admitted on 4/7/2010 with diagnoses that included Depression, Cerebrovascular Accident (CVA), Diabetes and Hypertension (HTN).

The Minimum Data Set (MDS) 2.0 Assessment dated 4/21/10 documented that this resident required total care and has modified independence for cognition. The MDS documented that the resident participates in activities "some of the time."

On 6/23/10 during the initial tour and on 6/25/10 at 3:30 p.m., the resident was observed in his bed covered with a sheet over his head. There was no television or radio by resident's bedside. On 6/29/10 at 3:00 p.m., the resident was observed in the hallway facing the nursing station. On 6/30/10 at 9:15 a.m., the resident was observed in his bed sleeping with glasses on. There were no activities observed to be provided for the resident.

The Comprehensive Care Plan dated 4/22/10 documented a goal for "Resident will continue to attend activities of choice within 90 days." The care plan further documented interventions: "Maintain positive manner when inviting resident to activities. Provide variety in activities based on resident's preferences. Include resident in group activities."

There was no documented evidence that resident #4 was assessed for therapeutic recreation.

An interview with Resident #4 was conducted on 6/30/10 at 9:15 a.m. Resident #4 stated he is so lonely. "No one comes to visit him." Resident #4 stated he would like someone to visit him. Resident #4 continued to state that he would like entertainment, likes music and tv.

An interview with the Recreation Therapist was conducted on 6/29/09. The Recreation therapist stated that she does not know what happened to the assessment. The Recreation therapist continued to state that they started a new computer system and the assessment would have been done prior to the care plan.

415. 11(a)(2)

Based on observations, record reviews and staff interviews, the facility did not ensure that infection control procedures were maintained for residents with pressure ulcers. This was evident for two (2) of thirty (30) sampled residents. (Residents #7 and #16)

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1.) Resident #7 is an 88 year old male with diagnoses that included Diabetes and Dementia.

On 6/25/10 at 10:25 a.m., during a wound care treatment observation of the Licensed Practical Nurse (LPN), the resident's diaper was removed and found that his sacral area pressure sore was not protected/covered with a dressing. The pressure sore was in contact with the plastic top part of the diaper. The wound measured approximately 6 centimeters (cm) by 7 centimeters, an area with slough and an area with eschar.

A review of the physician's order dated 6/18/10 documented: Polymer to Sacral PU (Pressure Ulcer) after cleaning with normal saline (n/s) daily and when necessary (prn).

A review of the Comprehensive Care Plan (CCP) dated 6/03/10 for Pressure Ulcer documented "apply treatment as per order."

The LPN was interviewed on 6/25/10 and stated that the resident should have had a dressing on his sacral area. The LPN stated that wound rounds were done this morning and that usually a protective dressing is place on the area.

The Unit Manager was interviewed on 6/25/10 at 11:30 a.m. and she stated that the resident was seen earlier today during wound rounds and that the procedure is to removed the old dressing and then to cover the wound and drape that area until the nurse is ready to do the wound care treatment. "I know we put protective dressing over the area and I don't know how this happened."

415.19(a)(1-3)

2.) Resident #16 is a 83 year old with diagnoses of Diabetes Mellitus, Hypertension, Dementia, and Acute Cerebrovascular Accident.

On the Minimum Data Set (MDS) 2.0 assessment dated 10/15/09 documented that the resident has moderately impaired cognition and requires total dependence with activities of daily living.

On 6/25/10 at 11:43 am., during a wound care observation, the Registered Nurse (RN) was observed taking off the old dressing from the right outer malleolus pressure ulcer. The RN cleaned the wound with normal saline and with the same gloved hands, proceeded to put on clean sterile dressing (Polymem) without washing hands and changing gloves.

On 6/25/10 after the wound treatment observation, the LPN was immediately interviewed and stated that she should have washed her hands and changed gloves after she took off the old dressing and before she applied the sterile dressing.

415.19(a)(1-3)

Based on observation, record review and staff interviews, the facility did not ensure that the facility is free of medication error rate of five (5) percent or greater as evidenced by: not administering medication at the time ordered by the physician and in accordance with the manufacturer's specification of the drugs. This was evident for two (2) of forty (40) opportunities for error resulting in a medication error rate of 5%. (Resident #1)

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 6/23/10 at 4:50 p.m., during medication pass observation, the Licensed Practical Nurse (LPN) was observed administering medication to Resident #1.

The LPN crushed and administered Flomax 0.4 mg. (milligrams) one cap orally PC (after meals) and Proscar 5 mg tab. (tablet) one tab P.O.

The physician's order dated 5/12/10 and 6/1/10 documented: Proscar 5 mg tab. crush caution one tab orally daily after a meal - *Do not handle if/or may become pregnant and Flomax 0.4 mg. cap one cap orally after meal(s) dinner "Do not open, crush or chew."

The medication nurse did not administer the medication as per the physician's order to administer the medications after a meal and not to open, crush or chew the medication.

The medication nurse was interviewed on 6/23/10 at 5:00 p.m. and stated "I have been crushing the medication for the pass two months and giving to the resident at 5:00 p.m. When the medication is given whole to the resident, he spits out the medication.

The physician was interviewed on 6/25/10 at 4:40 p.m. and stated the medication Proscar should not be open, it stated on the label potentially harmful to females and should be given after meals. Flomax also must be given after meals, the manufacturer recommended that the medication be given between 7-8 p.m.

415.12(m)(1)

Based on observation, document review and staff interview, the facility did not ensure that medications in the medication refrigerator were labeled in accordance with currently accepted professional standards including the expiration date when applicable. Specifically, three (3) opened vials of Lantus Insulin in the medication refrigerator were not dated when opened. This was evident for 1 of 4 nursing units. (Redwood Unit)

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

On 6/23/10, during the initial tour on the Redwood Unit from 9:30 a.m.-10:30 a.m., the medication refrigerator was found to have three (3) vials of Lantus Insulin. All three (3) vials of Lantus Insulin were opened and not dated. Each Lantus Insulin was identified with the name of the resident.

The unit License Practical Nurse (LPN) was interviewed on 6/23/10 at 10:00 a.m. and she stated, "we know that this should be dated." The vials were immediately removed by the LPN.

A review of the facility's Policy and Procedure dated 06/09 for "Medication Administration General Procedure," documents, "All multi-dose vials are to be dated at the opening and discarded 90 days except Lantus Insulin which is 30 days, unless otherwise specified."

415.18(d)

Based on record review and staff interview, the facility did not ensure that the physician's orders were followed. This was evident for one (1) of thirty (30) sampled residents. (Resident #11)

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #11 is a 61 year old male admitted on 5/30/08 with diagnoses that included Peripheral Vascular Disease (PVD) and Bilateral Below Knee Amputations of right and left lower extremities.

The Minimum Data Set (MDS) 2.0 assessment dated 6/10/10 documented that resident is alert and oriented and with independent cognitive status who requires extensive care and assistance with all Activities of Daily Living (ADL).

A review of the Physician's Orders dated 6/01/10 documented for routine annual laboratory workup. The following were ordered: "Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Complete Metabolic Panel (CMP), Chest X-Ray and Electrocardiogram (EKG).

A review of the record found no documented evidence of reports for the lab workup ordered on 6/1/10.

On 6/26/10 at 12:25 p.m., an interview with the Unit Manager was done and she stated that the evening shift did not log the order in the Diagnostic Log Book. "We missed it. I will take care of this right away."

415.11(c)(3)(ii)

Section 7.2.1.6 requires that approved, listed, delayed egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapter 12 through 42, provided that the following criteria are met.

(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.

(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.

(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door: Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.

Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.

(d) On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch (2.5 cm) high and not less than 1/8 inch (0.3 cm) in stroke width on a contrasting background that reads as follows:

PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

This Standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the signage with regard to the operation of the stairway doors equipped with delayed egress are provided adjacent to the door release devices on resident floors, in accordance with 7.2.1.6.1 (d).

This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

The findings include:
On June 23, 2010, at 10:00 AM to 2:30 PM, it was observed that the facility doors to the exit stairways on resident floors, are equipped with delayed egress locks. These locks are designed to automatically unlock upon actuation of the facility's fire alarm systems and when pushed at the door release device (door handle) with a delay of approximately 15 seconds. The doors, however, lack the signage stating that the door is to be pushed until alarm sounds and the door could be opened in 15 seconds, as stated under 7.2.1.6.1 (d). On June 23, 2010, at approximately 12:30 PM, the facility's director of engineering stated that the signage will be provided on the doors equipped with delayed egress, in accordance with 7.2.1.6.1 (d).

711.2 (a)(1)

NYCRR 713-2.23 (d)(2)(vi)
(a) Filter frames shall be durable and carefully dimensioned and shall provide air-tight fit with the enclosing duct work. All joints between filter segments and the enclosing duct work shall be gasketed or sealed to provide seal against air leakage.

This requirement is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the filter segments are installed and maintained to provide a continuous barrier against air leakage within the air handling unit #AC2, serving the west side of resident floors.

The findings include:
On June 23, 2010, at 10:00 AM to 2:30 PM, it was observed that the facility roof top air handling unit #AC2, serving the west side of the resident floors, is designed to use a series of throw-in type filters and bag type filters. Nevertheless, a complete row of throw-in type filter segments was missing in the air handling unit #AC2, located on the roof of the building. An approximately 4 inch gap was noted between the empty filters track and the enclosing duck work. All filter segments must be maintained in place to provide a tight fit with the enclosing duct work and to prevent against air leakage. On June 23, 2010, at approximately 11:00 AM, the facility's director of engineering stated that the company responsible for maintaining the air handling units will be contacted to install the missing filter segments so as to provide tight fit with the enclosing duct work.