Schuyler Ridge A Residential Health Care Facility

Based on record review and staff interview, the facility did not ensure that services provided or arranged by the facility were provided in accordance with each resident's written plan of care for 1 (Resident #108) of 14 residents reviewed during the recertification survey. Specifically, staff were using side rails for this resident that were not care planned or ordered by the physician and subsequently the resident was injured by the side rails. This resulted in no actual harm with a potential for more than minimal harm that was not immediate jeopardy. This was evidenced by the following:

Resident #108
The resident was admitted to the facility on 1/5/10 with diagnoses of depression, quadriparesis, anxiety. The Minimum Data Set (MDS) of 9/16/10 assessed that the resident had no memory or decision making impairments. It also assessed that the resident needed total assist of two staff for bed mobility. This MDS did not identify that the resident had side rails in use.

A Decision Tree for Side Rails as a Restraint was completed on 1/5/10, with the notation that side rails were not used or requested. The assessment side of this form documented no side rails as the resident was unable to use them secondary to quadriparesis (paralysis of four extremities).

The Comprehensive Care Plan (CCP) was reviewed and there was no plan for the use of side rails.

The Resident Profile/CNA Caregiver Record (used by caregivers to provide needed care to residents) dated 10/18/10, did not document to use side rails for this resident.

A nurse's note dated 5/26/10 documented that the resident was calling out at 1:30 am. The resident was found lying on her right side, with her legs hanging out of the right side of the bed. She had 5 centimeter redness to her lower abdomen and redness to her right hip. The resident stated that she woke up and was like that, "sliding out of bed." The supervisor was made aware of the incident. The same day at 2:30 am a note stated that the resident was repositioned with white pillows and other interventions would be discussed with the nurse manager. A nurse's note on 5/26/10 at 7:00 am, documented there was a discussion that this was the first time this had ever happened since admission and a concave overlay would be added to the resident's bed.

An Incident Report dated 10/24/10 at 9:55 pm identified a bruise on the left hand pinky finger for this resident. The resident's statement of what occurred was documented as, when getting dressed in the morning, it (the finger) got stuck in the side rail. The correction for the incident was to remove the side rails on 10/25/10.

During an interview on 11/3/10 at 8:49 am with the resident's CNA (certified nurse aide) she stated that the incident with the bruised finger happened when she was on vacation. She stated that she did not care for the resident when she first came in, but remembered the incident with her falling out of bed and the side rails going on the bed after that.

During an interview with the resident on 11/3/10 at 8:55 am she stated that she did not have siderails on her bed when she first came into the facility. She stated that she has spasms that cause her to move in bed. One night in May 2010 she was halfway out of the bed, after that side rails were put on her bed. She stated that her finger got injured several days ago. She stated that two CNAs were turning her and she heard a snap, it was her fingernail snapping, her finger was caught in the side rail. The resident stated that next day there was a bruise on the finger and she told the nurse.

During an interview on 11/3/10 at 1:46 pm with a CNA who has helped care for the resident at times, she stated that the resident had two side rails. She was not sure how long, but it was at least several months. She stated that the resident could not use the side rails.

During interviews on 11/3 and 11/4/10 at 8:30 am and 9:00 am respectively, with the Registered Nurse Manager (RNM) she was asked about the resident's bruise from the side rail. She stated that when she heard about it she took the side rails off the bed right away so nothing like that could happen again. She stated that the resident did not have a physician order for the side rails and they should not have been in use. She thought the CNAs may just have put the rails up thinking it was safer when rolling the resident over. She stated the resident was not assessed as needing the side rails. She did not know who put the side rails on the bed, she did not think the side rails were on the bed when the resident first came in. She stated the side rails were not appropriate for this resident because of her condition. She further stated that the CNAs should have looked at the Care Giver Record to know what to do for the resident, but apparently they did not.

10NYCRR 415.11(c)(3(ii)

Based on record review and staff interview, it was determined that the facility did not conduct the minimum testing requirements for the kitchen fire suppression system, during the standard recertification survey. 1998 NFPA 17A 5-3.1.1 requires semi-annual testing of the extinguishing system components including the operation of all detection system signals and releasing devices and associated equipment. Specifically, two of the last three required kitchen fire suppression system test reports indicated that not all signaling devices were tested. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows:

The inspection reports of the facility kitchen fire suppression system were reviewed on 11/04/2010 and revealed that the operation of the micro-switch was not checked during the 03/26/2009 and 09/17/2010 semi-annual tests.

The Environmental Services Director was interviewed on 11/04/2010 at 12:55 pm and acknowledged that the micro-switch was a signaling device and was not checked during the 03/26/2009 and 09/17/2010 semi-annual tests.

2000 NFPA 101 19.3.2.6, 9.2.3; 1998 NFPA 96 8.2, 1998 NFPA 17A 5-3.1.1(e)