Schuyler Ridge A Residential Health Care Facility

Based on observation and staff interviews during the recertification survey, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, on one of three units during observations of care by three Registered Nurses (RN#1, #2, and #3) and one Licensed Practical Nurse (LPN#1), the facility did not ensure that staff demonstrated practices and processes consistent with infection prevention and prevention of cross-contamination and the facility did not ensure that staff consistently practiced appropriate hand hygiene (hand washing) practices, after each direct contact with residents as indicated by professional practice. This resulted in no actual harm with the potential form more than minimal harm that is not immediate jeopardy. This was evidenced by the following;

Finding #1:
The facility did not ensure that staff demonstrated practices and processes consistent with infection prevention and prevention of cross-contamination. The following issues were identified during observations of care.

RN#1 did not clean an intravenous (IV) (a small catheter that is placed in a vein for administration of fluids or medication) port (the end cap of the IV, that is used to connect to the fluids or medications) before administering a normal saline (NS) (a non- medication solution, that is used to make sure the IV line is open) flush.

On 11/21/2011 @ 1:50 pm, during an observation of RN #1's administration of a intravenous (IV) antibiotic (a medication to treat infection that is given directly into vein) for resident #70, she did not clean the IV port before beginning the administration of the (NS) The surveyor requested that she stop and asked if she was going to do anything before giving the NS. She thought a minute and then asked if she should clean the IV port with alcohol first. She returned to the medication room to obtain the alcohol pads needed to clean the port. When she returned to the resident bedside she proceeded to start the administration of the NS and the IV antibiotic following the proper cleaning of the IV port.

An interview with the Assistant Director of Nursing (ADON) and the Infection Control Prevention Nurse (ICPN) was completed on 11/28/2011 at approximately 1:30 pm. When the surveyor asked about the facility practice and procedure regarding the administration of a flush or a medication into an IV port, they both stated that the IV port should be cleaned with alcohol before the administration.

RN#2 transported the supplies needed to complete the IV antibiotic infusion in her uniform pocket and placed an uncapped syringe directly on the residents bed.

At approximately 3:20 pm on 11/21/2011, RN#2 was observed as she prepared to complete the IV antibiotic for resident #70. She was observed gathering NS syringe, Heparin (a medication used to keep the IV line open) syringe, alcohol pads, and gloves from the medication room and placing them in her uniform pocket to bring to the residents room. RN#2 did not use a clean surface to set the supplies on and placed the uncapped Heparin syringe directly on the resident's bed. She proceeded with the completion of the IV antibiotic by disconnecting the IV, cleaning the port with alcohol and administering the NS. As RN#2 started to pick up the Heparin syringe from the resident's bed, the surveyor asked her to stop. The surveyor asked RN#2 if she could use that syringe, she replied no, she would have to go to the medication room to get another one. The surveyor asked why she couldn't use that syringe, she identified that it was uncapped and had touched the resident's bed so, it was not considered sterile. When RN#2 was asked if the supplies that were placed in her uniform pocket were considered clean, she responded that they would not be considered clean.

Interview on 11/28/2011 at 1:30 pm with the ADON and the ICPN regarding the use of uniform pocket to transport supplies and placing the uncapped sterile Heparin syringe directly on the resident's bed was completed. The ADON and the ICPN responded that nurse's uniform pockets are not considered clean and should not be used to transport supplies. They also stated that the sterile Heparin syringe should not have been placed directly on the resident's bed, especially if it was uncapped. The syringe and the contents would be considered contaminated or dirty and should not be used.

RN#3 moved an alarmed floor mat with gloved hands and was going to touch the resident to assist in positioning him during care, without changing the dirty gloves.

RN#3 was observed on 11/28/2011 at 11:50am. RN#3 was assisting the Registered Nurse Manager with the sterile peripherally inserted central catheter (PICC) (a long catheter that is inserted into a vein, usually in the arm, with the tip at a large vein) dressing change and care. She had clean gloves on both hands to assist with the care. RN#3 noticed that the alarmed floor mat needed to be moved from the area next to the bed before the care could begin. RN#3 moved the alarmed floor mat out of the way and returned to the resident bedside to assist in positioning without changing her gloves or washing her hands. The surveyor intervened and asked if she was forgetting something. RN#3 responded that she was not the one that was going to be doing the PICC line dressing change and care; she was assisting for positioning of the resident only. The surveyor then asked if her gloves and hands should be clean to touch the resident and she responded yes. The surveyor then asked if her gloved hands were considered clean after touching the alarmed floor mat and she responded no. RN#3 then removed the dirty gloves and washed her hands before putting on clean gloves to assist with the resident care.

A follow-up interview was completed with the ADON and the ICPN on 11/28/2011 at 1:30 pm regarding RN#3 not changing her gloves or completing hand hygiene after moving the alarmed floor mat. They both stated that the gloves would be considered dirty after touching the alarmed floor mat and should have been changed prior to contact with the resident.

LPN#1 was observed to place medication in her uniform pocket and then return it the medication cart drawer.

During the medication pass observation on 11/28/2011 at 10:00 am, LPN#1 prepared oral medications and an inhaler as ordered for resident #87. Upon completion of the medication and inhaler administration, she placed the inhaler box into her uniform pocket. She then returned to the medication cart and removed the inhaler box from her pocket and returned it to the appropriate drawer on the cart. When asked by the surveyor if her uniform pocket was considered clean, she responded no. When asked by the surveyor if the medication drawers were considered to be clean, she responded yes. She then stated that she shouldn't put medications in her pocket and then return them to the cart.

During the interview with the ADON and the ICPN on 11/28/2011 at 1:30 pm, when asked if a uniform pocket is considered clean and should be used to transport supplies or medications, they responded no. The nurse's uniform pockets are not considered clean and should not be used to transport supplies.

Finding#2:
The facility did not ensure that staff consistently practiced appropriate hand hygiene (hand washing) practices, after each direct contact with residents as indicated by professional practice

On 11/28/2011 at 9:45 am, LPN#1 was being observed during a medication pass. During the medication pass to resident #42, she prepared the crushed medication and applesauce in addition to pudding thick water to administer to the resident. LPN#1 was observed to touch the resident and provide full assistance by spoon feeding the medication to the resident. LPN#1 returned to the medication cart and began touching the cart, various items on the cart and the medication binder without completing hand hygiene. When interviewed she stated that she would wash her hands once she completes the entire medication pass for the resident including her signature to the medication record. When asked if the medication cart was considered a clean area, she responded yes. When asked if her hands were considered clean after the fully assisted medication pass to resident #42, she responded no. The medication cart did not have alcohol based hand rub (ABHR) to use for hand hygiene. She immediately washed her hands and went to the medication room to obtain ABHR to place on the medication cart. She stated that the carts usually have ABHR on them and she forgot to check before she started her medication pass.

The ADON and ICPN were interviewed on 11/28/2011 at 1:30 pm, regarding hand hygiene. The ICPN stated that good hand hygiene should be part of each medication pass and that LPN#1 should have completed hand hygiene after the full assist medication administration to resident #42. She also stated that ABHR should be kept on each medication cart for use when hand washing with soap and water is not required.

An interview/discussion with the Director of Nurse was completed on 11/29/2011 at approximately 8:15 am regarding the infection control issues identified and during observations of care. She stated that IV ports should be cleaned with alcohol before use, uniform pockets should not be used to transport supplies, gloves should be changed when dirty, and good hand hygiene should followed during medication administration and at all times.

10NYCRR 415.19(a)(1-3)
10NYCRR 415.19(b)(4)

Based on record review and staff interview the facility did not ensure that it maintained clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized for one(# 65) of 1 resident reviewed for dialysis during the recertification survey. Specifically: physician ordered intake and output (I&O) records were not complete. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident 65
The resident was admitted on 1/6/11 with diagnoses of end stage renal disease on dialysis, diabetes and diverticulosis. The Minimum Data Set (MDS) of 10/7/11 assessed the resident understands, is understood, had no cognitive or decision making impairment and received dialysis.

The Physician Orders dated 11/23/11 documented to do intake and output every shift.

During an interview on 11/28/11 at 11:20 am an Licensed Practical Nurse, who cared for the resident, stated the resident is on a 1000 cc fluid restriction per day and they record I&O. She said it is totaled at the end of the shift.

The I&O records were reviewed for the past two months with the following results: in October. intakes were totaled only 4 times, with 21 blanks on the record; in November there were no intake totals with 21 blanks as of the 11/27/11.

During an interview on 11/28/11 at approximately 2:00 pm the Registered Nurse Manager (RNM) stated the I & Os should be completed and totaled. She stated that was not the case for this resident.

10 NYCRR 415.22(a)(1-4)

Based on record review and staff interview the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (# 146) of three residents reviewed for accidents during the recertification survey. Specifically: the Comprehensive Care Plan (CCP) documented to place a Dycem (antislip mat) under the residents wheelchair cushion after a fall along with other interventions. This was not implemented and the resident subsequently had a fall on 9/10/11. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident 146
The resident was admitted to the facility on 8/11/11 with diagnoses of fractured tibial plateau, dementia with agitation and history of falls. The Minimum Data Set (MDS) of 8/18/11 assessed that the resident is understood, usually understands, had short term memory impairment, no long term memory impairment and moderately impaired decision making. It further documented a fall prior to admission, fall in past 2-4 months, and a fracture related to a fall in 6 months.

A Fall Risk Assessment dated 8/11/11 documented a score of 15 ( a score of 10 or more indicated a risk of falling).

A Fall Tracker documented that the Fall Risk Assessment score was 15 and that bed and chair alarms and a floor mattress were started on 8/11/11.

An Incident Report (I&A) dated 8/13/11 documented a fall on 8/13/11 at approximately 3:45 pm where the resident may have slid from the wheelchair. It documented under the investigation of the event and intervention that the resident was found sitting on the floor in front of the wheelchair with the wheelchair tipped over. The resident may have slipped from the wheelchair. Dycem was placed under the cushion, under chair pad alarm as well as over chair pad alarm. The "other" section of the I&A documented a Dycem was placed under (the wheelchair) cushion, alarm on resident in wheelchair to prevent sliding.

The Comprehensive Care Plan (CCP) for falls dated 8/30/11 documented the following approaches: bed and chair alarms, bed against the wall, mattress on the floor next to the bed, Dycem under wheelchair cushion, and alarm on resident.

An I&A dated 9/10/11 documented the resident had a fall from the chair on 9/10/11 at approximately 10:00 am. It documented under investigation of event and intervention that a staff member witnessed a fall from the wheelchair to the floor. Staff stated the resident slid to the floor on her buttocks. The resident was put on 1:1 supervision until less agitated. Nothing on this I&A documented whether the Dycem had been in place under the wheelchair cushion when the resident fell.

During an observation of the resident's transfer on 11/28/11 at 4:45 pm no Dycem was observed in the residents wheelchair. One of the Certified Nurse Aides (CNA) who performed the transfer was asked if there was a Dycem in the chair. She said no, she did not think so. She stated she did not know if the resident needed a Dycem and went to look in the residents room.

The Care Card (used by caregivers to provide needed care to the resident) in the residents closet did not document to use a Dycem. The CNA said she did not remember ever seeing a Dycem used for the resident. No Dycem was found in the room at this time.

During an interview on 11/29/11 at 9:05 am with a day CNA, who worked with the resident, she stated the resident is not supposed to have a Dycem in her chair. She stated they do no put Dycem in the wheelchair and that they had never put one in the wheelchair.

During an interview on 11/29/11 at 11:15am with the Registered Nurse charge nurse, who had worked with the resident since her admission, was asked her if she remembered a Dycem in the residents chair. She said she did not remember ever seeing one at any time.

10 NYCRR 415.12(h)(1)

Based on observation, record review and interview the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care for one (# 146) of three residents reviewed during the recertification survey. Specifically: the comprehensive care plan (CCP) was not followed to walk the resident to and from meals. The CCP also was not followed to put a Dycem in the residents wheelchair. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by:

Resident 146
The resident was admitted to the facility on 8/11/11 with diagnoses of fractured tibial plateau, dementia with agitation and history of falls. The Minimum Data Set (MDS) of 8/18/11 assessed that the resident is understood, usually understands, had short term memory impairment, no long term memory impairment and moderately impaired decision making. It further documented a fall prior to admission, fall in past 2-4 months, and a fracture related to a fall in 6 months.

Finding 1
A Physical Therapy (PT) progress note dated 11/4/11 documented a discussion with the Nurse Manager (NM) regarding the use of a wheelchair versus walking. The resident was currently using the wheelchair because of anti-tippers for seating at meals, etc. The recommendation was to use a recliner or wheelchair with a cushion. Ambulation was all unit destinations with wheeled walker or HHA (hand hold assist) of 1 staff, and to ambulate to/from all meals.

The CCP for Activities of Daily Living (ADL) dated 8/30/11 was updated under ambulation on 10/28/11 and documented Assist of 1 with a wheeled walker or HHA for all unit destinations and ambulate to and from meals.

The care card (used by caregivers to provide needed care to residents) dated 11/7/11 documented to ambulate (the resident) to and from all meals. Under the heading for ambulation it documented to ambulate to all unit destinations with a wheeled walker or HHA of 1 staff.

On 11/28/11 at 9:50 am the resident was observed being wheeled out of her room to the dining area in her wheelchair by a certified nurse aide (CNA). At 11:06 am the resident was observed being wheeled by staff down the hallway past nurses station to the window garden area. At 11:15 am the resident was observed being wheeled around the nurses station by the same staff person. At 1:35 pm the resident was wheeled from the dining room to an area by the nurses station by a CNA.

During an interview on 11/29/11 at 9:35 am the Physical Therapist (PT) stated staff should try to walk resident to and from meals.

During an interview on 11/29/11 at 9:05 am the Certified Nurse Aide (CNA) who wheeled the resident from the dining room at 1:35 pm on the11/28/11 was asked why she did not try to walk the resident from the dining room. She had no answer.

During an interview on 11/29/11 at 9:18 am the Registered Nurse who wheeled the resident to the window on 11/28/11 stated she has not tried to actually walk the resident.

Finding 2
The Comprehensive Care Plan (CCP) for falls dated 8/30/11 documented Dycem was to be placed under the resident's wheelchair cushion.

During an observation of the resident's transfer on 11/28/11 at 4:45 pm no Dycem was observed in the residents wheelchair. One of the Certified Nurse Aides (CNA) who performed the transfer was asked if there was a Dycem in the chair. She said no, she did not think so. She stated she did not know if the resident needed a Dycem and went to look in the residents room.

The Care Card (used by caregivers to provide needed care to the resident) in the residents closet did not document to use a Dycem. The CNA said she did not remember ever seeing a Dycem used for the resident. No Dycem was found in the room at this time.

During an interview on 11/29/11 at 9:05 am with a day CNA, who worked with the resident, she stated the resident is not supposed to have a Dycem in her chair. She stated they do no put Dycem in the wheelchair and that they had never put one in the wheelchair.

10 NYCRR 415.11(c)(3)(ii)

Based on observation, resident interview, and staff interview during the recertification survey, the facility did not ensure that the results of the last New York State Department of Health recertification survey were posted in a place readily accessible to residents. Additionally,the facility did not ensure that a notice of their availability was posted. Specifically, on 3 of 3 units, the facility did not ensure that the previous year's survey results and approved plan of correction were readily accessible or visible for individuals wishing to examine them without having to ask a staff person to see them. This resulted in no actual harm with the potential for minimal harm that is not immediate jeopardy. This was evidenced by:

During an interview on 11/29/11 at 9:35 am the Resident Council President stated he did not know if the survey results were available or where they would be posted if they were available.

There were no survey results posted in the facility lobby on 11/29/11 at 9:45 am.

On 11/29/11 at 10:10 am, the surveyor asked the Administrator (AOR) where the last year's survey results were located. In response, she stated the results were on the wall near the lobby. When the surveyor asked where, she pointed to a wooden pocket rack on the wall with a printout of survey results sticking up in one of the wooden pockets. She stated that everyone was told on admission about their location, and then stated that maybe they needed to label the wooden pocket with state survey results for better recognition of it. She then stated that the survey results were also posted on each of the resident units.

The Clifton Hills unit was observed on 11/29/11 at 10:15 am, by the surveyor and AOR, the survey results were observed by the surveyor after the Administrator took her to where they were posted and showed her where to look. These results were observed to be posted approximately five feet from the ground, on a wall in the unit's dining area, stapled to a cork board in a manila folder above a book case filled with activity supplies. The folder had a small label reading "Survey Results" in small print placed on the front of it.

The Ensign Point unit was observed by the surveyor on 11/29/11 at 10:20 am and the survey results could not be located. The Administrator was on the unit at that time and then stated that the survey results should be posted on a cork board in the unit dining area just as they had been on the other unit. The surveyor then went to look at the cork board on this unit in the dining area and no postings were observed on the cork board.

The surveyor then went to the Fenimore unit on 11/29/11 at 10:24 am to locate the survey results. The survey results for this unit were again located approximately five feet off the ground, on a wall in the unit's dining area, stapled to a cork board in a manila folder with a small label reading "Survey Results" in small print on the front of it.

On 11/29/11 at 10:32 am, the Director of Social Work came to inform the surveyor that because one resident had a history of taking things down from the walls on the one unit (Ensign Point), they had put the survey results in a binder at the nurse's station and stated that these were clearly labeled. Upon surveyor observation of this at 10: 34 am, a green binder was located behind a vase filled with silk flowers. The label on the front of this binder could not be read until it was pulled out from behind the vase by the surveyor. Once pulled out from behind the vase, a small label with small print read "Resources and Information for Families". It gave no identifying information that the last year's survey results were located in the binder. The surveyor opened the binder and found it had three sections titled "Policies'', "Advanced Directives'' and " Hospice''. The survey results were not immediately identifiable and the surveyor located the survey results only after flipping through the section for "Policies" .

10 NYCRR 415.3 (1)(c)(1)(v)

Based on staff interview and record review during the standard recertification survey, it was determined that the staff were not familiar with the facility's fire response policy and adopted fire-response regulations. NFPA 101 Life Safety Codenone 2000 edition section 19.7.2.3 states that employees shall be trained in the use of a code phrase to insure the transmission of an alarm when the individual who discovers a fire must immediately go to the aid of an endangered individual (code phrase for fire). Specifically, 4 of 8 staff interviewed were not familiar with the correct procedure used when an endangered individual requires immediate aid. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

Interviewed on 11/21/2011, activities director at 8:40 am, one certified nursing assistant at 9:35 am, and one dietary aid at 9:15 am did not know the code phrase for fire.

One housekeeper did not know to close the door to the fire room when interviewed on 10/25/2011 at 10:10 am.

The facility's emergency fire procedure was reviewed on 11/21/2011. The policy requires that staff persons are to announce " Code Red and the location " upon discovering a fire situation.

2000 NFPA 101 19.7.2.3; 1997 NFPA 101 13-7.2.1; 10 NYCRR 415.29, 711.2(a)(1)