Meadowbrook Care Center, Inc

Based on observation, staff interview and record review during the Recertification Survey, the facility did not ensure that one resident's dignity was maintained during one breakfast meal. Specifically, Resident # 2 was observed unintentionally pouring a cup full of breakfast cereal onto her lap without timely intervention from nursing staff. This resulted in no actual with the potential for more than minimal harm that is not Immediate Jeopardy.

The finding is:

Resident # 2 has diagnoses that include Dementia and Diabetes.

An observation on 7/12/11 at 8:15 AM was completed in the 3A dining room during the breakfast meal.

A Minimum Data Set assessment dated 5/12/11 documented that the resident required total assistance of one staff person for feeding (4/2).

Resident # 2 was observed seated in her wheel chair in front of her breakfast tray. She was wearing a plastic clothing protector and was holding a cup filled with what appeared to be a hot breakfast cereal, cream of rice. The resident's arm was extended away from her mouth and the cup that was filled with the cereal was at an angle. The cereal was observed pouring from the cup onto the resident's lap. This continued several moments and although nursing staff were in close proximity, the resident continued unassisted to pour the cereal onto herself.

During an interview with the Charge Registered Nurse (RN) Manager on 7/13/11 at 10:00 AM the RN stated that she did not know who set up the resident at the breakfast meal. The RN also stated that the person who set up the breakfast tray should have spoon fed the resident the breakfast cereal. She further stated that there were times that Resident #2 was able to feed herself the liquids on her tray and that the resident was having a problem with her psychiatric medications which needed to be adjusted.

415.5(a)

Based on record reviews and staff interviews during the Recertification Survey, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs. This was evident for 2 of 16 residents reviewed for Psychoactive medications in a total of 30 records reviewed. Specifically, 1) Resident #20 received Haldol (an antipsychotic) injection and there was no documented evidence of non-pharmacological interventions attempted prior to administration; 2) Resident #30 received Haldol injection and Risperdal tablet (an antipsychotic) as needed (PRN) for agitation and there was no documented evidence of non-pharmacological interventions attempted prior to the use of the drugs. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #20 has diagnoses including Respiratory Failure and Cerebrovascular Accident (CVA).

The Minimum Data Set (MDS) Admission Assessment dated 4/18/11 documented the resident is severely impaired and that the resident received psychotropic medication during the last 7 days since admission.

The April 2011 and May 2011 Monthly Physician's Order documented Haldol 0.5 milligram (mg) intramuscular (IM) every 12 hours PRN for Agitation.

The April 2011 and May 2011 Medication Administration Record (MAR) documented Haldol 0.5 mg IM every 12 hours PRN for Agitation. The MAR documented that Haldol IM was administered to the resident dated 4/21/11 and 5/10/11. There was no documented evidence in the MARs that an alternate non-drug intervention was attempted prior to administration.

The Nurses' Notes dated 4/21/11 and 5/10/11 did not contain documented evidence that non-pharmacological interventions were attempted prior to PRN Haldol IM administration.

2) Resident #30 has diagnoses including Ascites and Pleural Effusion.

A Quarterly MDS Assessment documented the resident is moderately impaired and that the resident received antidepressant medication during the last 7 days.

The Physician's Order dated 5/23/11 documented Risperdal 0.25 milligram (mg) by mouth (PO) every 4 hours PRN.

The Physician's Order dated 6/3/11 documented Haldol 0.5 mg IM every 6 hours PRN for Agitation.

The May 2011 MAR documented Risperdal 0.25 mg PO every 4 hours PRN. The resident was administered Risperdal 9 times from 5/23/11 through 6/24/11. There was no documented evidence in the MARs that an alternate non-drug intervention was attempted prior to administration of the Risperdal.

The June 2011 MAR documented Haldol 0.5 mg IM every 6 hours PRN for Agitation. The MAR documented that Haldol IM was administered to the resident on 6/3/11. There was no documented evidence in the MARs that an alternate non-drug intervention was attempted prior to administration of Risperdal.

The Nurses' Notes dated 5/23/11 through 6/24/11 did not contain documented evidence that non-pharmacological interventions were attempted prior to the PRN Haldol IM or Risperdal PO administration.

The Medical Director was interviewed on 7/14/11 at 9:00 AM. The Medical Director stated that non-pharmacological interventions should be attempted and documented prior to the administration of a PRN antipsychotic medication.

The Director of Nursing Services (DNS) was interviewed on 7/15/11 at 10:00 AM. The DNS stated that when residents receive PRN medications for agitation, there should be documented evidence of some interventions, such as a diversional activity prior to the administration of the medication.

The Licensed Practical Nurse (LPN), one of the licensed staff that administered the PRN Haldol injection to Resident #20, was interviewed on 7/15/11 at 11:30 AM. The LPN stated that she did not document any non-drug interventions prior to PRN Haldol injection administration.

The facility's policy dated 10/12/09 titled Psychoactive Drugs documented that "It is our policy to consider alternate (non-drug) means of managing resident behavior problems when possible. All disciplines are encouraged to explore factors responsible for resident behavior and to participate in the planning of non-drug interventions... Document behavior and surrounding circumstances in a progress note ...".

415.12(1)(1)

Based on observation and staff interviews during the Recertification Survey, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident on 1 of 7 Nursing Units toured. Specifically, during an observational tour on Unit 2B, a medication cart was noted to be unattended in the hallway in front of the Nurses Station with medication placed in the side bin of the cart and two residents in wheelchairs were noted nearby. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During an observational tour of Unit 2B on 7/12/11 at 6:25 AM, it was noted that a medication cart was left unattended in the hallway by the Nurses Station. One blister pack containing 16 capsules of Phenytoin sodium (an anticonvulsant) 100 milligrams, one blister pack containing 29 tablets of Levothyroxine sodium (thyroid medication) 50 micrograms and one packet of Ipratropium bromide (an inhalation solution) 0.02% was observed in the side bin of the medication cart. Additionally, it was observed that two residents in wheelchairs were located in proximity to the medication cart. There were no staff observed to have been in view of the medication cart that was located in the hallway.

An interview with the Licensed Practical Nurse (LPN) Medication Nurse was conducted on 7/12/11 at 6:30 AM. The LPN stated that she had intended to dispense the medication to a resident, but a supervisor came to begin a treatment for that resident and she had meant to put the medication away. The LPN further stated that the medication should have been put into the locked medication cart and not left in the bin.

The Director of Nursing Services (DNS) was interviewed on 7/15/11 at 8:30 AM. The DNS stated that no medications should be left on the medication cart when the cart is not in use, but should be locked in the cart.

415.12(m)(1)

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that physician's orders were signed and dated in a timely fashion as required. This is evident for one (Resident #30) of three closed resident records in a total of thirty sampled resident records reviewed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #30 has diagnoses including Ascites and Pleural Effusion. The resident expired in the facility on 7/11/11.

The medical record contained a total of 21 Physician's Telephone Orders (TO) dated 6/9/11 through 7/11/11 that were not signed and dated by the Physician.

An interview with the Director of Nursing Services (DNS) was conducted on 7/14/11 at 10:00 AM. The DNS stated that the Physician's TOs should have been signed and dated by the Physician within 48 hours as per policy.

An interview with the Medical Director was conducted on 7/14/11 at 11:00 AM. The Director stated that Physician's TOs are to be signed and dated by the Physician within 48 hours.

The facility's policy dated 10/7/05 titled Telephone Orders (Verbal) documented that the Attending Physician signs the telephone orders within 48 hours of being given.

415.15(b)(2)(iii)

Based on observation and staff interviews during the Recertification Survey, the facility did not ensure that residents receive proper treatment and care for tracheostomy care and respiratory care. This was evident during one of one tracheostomy care observation conducted of 4 residents with tracheostomy tubes in a total of 30 sampled residents reviewed. Specifically, the Director of Respiratory Therapy (RT) was observed suctioning Resident #20's tracheostomy tube secretions. The Resident's mouth was frothing with copious amounts of salivary secretions. The RT did not suction the Resident's mouth. The RT used the same heavily soiled tracheostomy tube T-gauze dressing to wipe the peri-tracheostomy area before applying a clean T-gauze dressing. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #20 has diagnoses including Respiratory Failure, Cerebrovascular Accident (CVA) with Right Hemiparesis, and has a Tracheostomy Tube.

The Minimum Data Set (MDS) Admission Assessment dated 4/18/11 documented the resident is severely impaired and received respiratory treatments such as Oxygen therapy, suctioning, tracheostomy care and is on a ventilator or respirator.

The resident was observed in bed with her mouth full of frothing saliva draining by the right side of her mouth on 7/14/11 at 11:35 AM. The tracheostomy T-gauze dressing was heavily soaked with yellowish mucoid secretions. The resident was noted to be trying to cough out the secretions through the tracheostomy tube.

A tracheostomy care dressing observation with the RT was conducted on 7/14/11 at 11:45 AM. It was observed that after suctioning the resident's tracheostomy tube, the RT removed a heavily soaked T-gauze dressing from the tracheostomy site. The RT then used the same T-gauze dressing to wipe the site area. The RT proceeded to apply and slide a new T-gauze dressing to the tracheostomy tube site area. The RT then left the resident.

The RT was immediately interviewed and stated that he had completed his care for the resident. It was brought to the attention of the RT that the resident's mouth was never suctioned with the copious amounts of salivary secretions still draining out over the right side of her mouth and that the RT used the same heavily soaked T-gauze to wipe the tracheostomy site before applying a new T-gauze dressing. It was also observed that there was no Yankuer suction piece at the resident's bedside as part of the suctioning supply kit.

An interview with the Registered Nurse (RN) Infection Control Coordinator/Inservice Coordinator was conducted on 7/15/11 at 11:15 AM. The RN stated that the heavy soaked T-gauze dressing should have been thrown directly into the waste bin and not used to wipe the tracheostomy area. The RN also stated that the resident should have been suctioned per mouth with a Yankuer suction piece to provide care and comfort.

The facility's Infection Control policy was requested from the Director of Nursing Services (DNS) but was not provided to the survey team as of the survey exit time.

415.19(a)(1-3)

Based on observation and staff interview during the Recertification Survey, the facility did not ensure that all food was handled in order to maintain sanitary conditions. Specifically, a Certified Nurse Aide (CNA) was observed touching a resident's slice of bread with her bare hands during meal tray service. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During a breakfast meal observation on 7/12/11 at 8:10 AM in the Unit 3A Dining Room, the following was noted: A CNA was observed setting up a resident's breakfast tray. The CNA made direct contact with a slice of wheat bread with her bare hand while she removed the plastic wrapper and when she folded the bread in half with her fingers.

An interview was conducted with CNA on 7/12/11 at 10:50 AM. The CNA stated that she was unaware that she had made direct contact with her bare hand and a slice of bread served on a resident's tray and that she knew not to do so.

415.14(h)

Determination of waiver request is in process.

Life Safety Code section 19.1.6.2 and Table 19.1.6.2 limit the height of buildings that are built of unprotected non-combustible construction (NFPA 220 Type II (000) building construction) to be only two stories with complete automatic sprinkler system.

Based on observation and staff interview, it was determined that the facility did not ensure that the nursing home building that is built of unprotected non-combustible construction (NFPA 220 Type II (000) building construction) were not more than two stories in height with a complete automatic sprinkler system.

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

Corridor doors are provided with impediments to the closing and latching of the doors in the event of a fire. Double doors to PT and OT have active and inactive leaves that require four separate actions to close and latch the doors.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-3.6.3

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

42 CFR 483.70(a)(1):

Lounges (waiting areas) on patient sleeping floors are open to the corridor and direct visual supervision of the areas is not provided.
483.70(a), 711.2(a)(1), NFPA101-2000: 19-3.6.1

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

In several areas (e.g. Library, Personal Care Room, Caf) exit access doors used by residents were not at least 44 inches wide.
483.70(a)(1), 711.2(a)(1), NFPA 101-2000: 19-2.3.5

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

The door swing arrangement for the PT area obstructs the corridor. The active leaf projects over 24 inches into the corridor.
483.70(a)(1), 711.2(a)(1), NFPA 101-2000: 7-1, 19-2.1

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued.

Please indicate if the facility wishes the waiver (s) to be continued or provide a plan of correction.

A 33 foot dead end corridor was noted on unit 2C.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-2.5.10