Meadowbrook Care Center, Inc

Based on record review and staff interviews during the recertification survey, the facility did not ensure that two of thirty sampled residents had documented evidence of Blood Pressure (BP) monitoring or pulse monitoring for the use of anti-hypertensive medications and orthostatic BP monitoring for the use of an antipsychotic medication. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. (Resident #12 and #27)

The findings are:

1) Resident #12 has diagnoses including Hypertension, Transient Ischemic Attack (TIA), and Congestive Heart Failure.

A Nurse's Note dated 2/11/10 at 8:45 PM documented that the resident was in the bathroom and became unresponsive to verbal stimuli after having a bowel movement. Vital signs were taken and the Physician was made aware.

A Nurse's Note dated 2/16/10 at 6:30 PM documented that the resident became unresponsive in the dining room, had a blank stare and was drooling. The Physician was notified and ordered the resident to be transferred to the hospital. The resident was admitted with diagnoses of a TIA and Sepsis.

The MAR dated 1/28/10-2/26/10 documented to administer Labetalol 200 mg tablet every 12 hours for Hypertension. The MAR contained specific parameters for monitoring BP and pulses. The pulses were to be monitored daily. Review of the MAR dated 1/28/10-2/26/10 documented seven occasions where anti-hypertensive medication was administered without documented BPs. Additionally, review of the MAR did not reveal any documented pulses for this time period.

There were no recorded BPs on the MAR for 2/14/10 (AM or PM) and no 2/15/10 AM BP. The resident was also receiving Risperdal 0.25 mg tablet every evening at 7 PM without documented evidence that the orthostatic BP was taken prior to the administration of Risperdal on 2/15/10.

The Pharmacy Consultant was interviewed on 5/14/10 at 10:30 AM and stated that he was a member of the facility pharmacy committee and that the MARs are reviewed by the staff he has working in the facility. The Pharmacy Consultant stated that the facility has policies requiring staff to monitor antihypertensive medication and antipsychotic medications with blood pressure and pulse parameters. The Pharmacy Consultant further stated that the Physician can choose to place a resident that has stabilized on weekly parameters.

An interview was held on 5/14/10 at with the 3 PM-11 PM Licensed Practical Nurse (LPN) who administered Resident #12's evening medications. The LPN stated that she was familiar with Resident #12 and her medications. The LPN stated that if she had not administered the resident medication or if she had not taken her vital signs she would have documented why the medications could not be administered. The LPN stated that she most likely had not signed for the medication or vital signs because of her workload or she may have been attending to family members.

An interview was held on 5/14/10 at 11:00 AM with the Director of Nursing (DON). The DON stated that she would expect the medication nurse to document the BP and/or pulses on the MARs prior to administering medications that have specific monitoring parameters. Additionally, the DON stated on 5/14/10 at 11:30 AM, when the drug manufacturer has specific parameters established prior to the administration of certain medications, the pharmacy prints the parameters on the MAR.

An interview was held on 5/14/10 at 12:30 PM with the 7 AM-3 PM LPN who administered medications to both Residents #27 and #12. The LPN stated that she does monitor blood pressures, but must have forgotten to document the BPs on the MARs.

2) Resident # 27 has diagnoses including Hypertension and Status Post Cerebral Vascular Disease with Right Hemiplegia.

The current Physician's Orders dated 5/07/10 included Amlodipine (an antihypertensive drug) 5 milligram (mg) tablet by mouth daily with parameters to hold the medication if the systolic BP is less than 110 mm Hg and Risperdal 0.5 mg tablet by mouth daily at hour of sleep.

The Medication Administration Record (MAR) dated 2/07/10-3/09/10 documented on eleven occasions that Amlodipine 5 mg was administered without a documented BP. Additionally, on 3/01/10 and 3/08/10 there was no documented evidence that weekly orthostatic BP's were taken on the 11 PM-7 AM shift as requested on the MAR.

The MAR dated 3/10/10-4/07/10 documented on eighteen occasions that Amlodipine 5 mg was administered without a documented BP. Additionally, on 3/29/10 there was no documented evidence that the weekly orthostatic BP was taken on the 11 PM-7 AM shift as requested on the MAR.

The MAR dated 4/08/10-5/07/10 documented on twenty-two occasions that Amlodipine 5 mg was administered without a documented BP. Additionally, on 4/12/10 and 4/26/10 there was no documented evidence that weekly orthostatic BPs were taken on the 11 PM-7 AM shift as requested on the MAR.

The MAR dated 5/08/10-5/14/10 documented on one occasion that Amlodipine 5 mg was administered without a documented BP. Additionally, 5/10/10 there was no documented evidence that the weekly orthostatic BP was taken on the 11 PM-7 AM shift as requested on the MAR.

The Director of Nursing (DON) was interviewed on 5/14/10 at 11:30 AM and stated that when the drug manufacturer has specific parameters established prior to the administration of certain medications the pharmacy prints the parameters on the MAR.

An interview was held on 5/14/10 at 12:30 PM with 7 AM-3 PM Licensed Practical Nurse (LPN) who administered medications to both Residents #27 and #12. The LPN stated that she does monitor blood pressures, but must have forgotten to document the BP's on the MAR's.

Review of the Pharmacy Manual Policy (Policy #32) documented 1) all residents receiving the following medications shall have their radial pulse checked and recorded on the Medex (MAR) prior to the first dose daily. Amlodipine and Labetalol are listed medications.
2) all residents receiving the following medications shall have a blood pressure taken and recorded on the MAR weekly. Amlodipine and Labetalol are listed medications.
3) all residents receiving the following antipsychotic medications shall have orthostatic BP's taken weekly. Risperdal is a listed medication.

415.11(c)(3)(ii)

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.

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

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.

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.

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