Nottingham Rchf

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure one food item (roast beef) was prepared under sanitary conditions. Specifically, roast beef was not cooled in a timely manner. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility menu, dated April 5, 2010, documented the first choice entree for supper for Thursday, October 14, 2010 was French dip au jus (roast beef).

On October 13, 2010 at 4:15 PM, the surveyor observed a whole roast beef (approximately 20 pounds) cooling on the counter in the kitchen.

On October 14, 2010 at 7:40 AM, the surveyor observed a cooked roast beef in the kitchen's walk-in refrigerator; it was cut in half and covered with plastic wrap. The temperatures of the 2 pieces of roast beef were 46 degrees F. and 44 degrees F. The refrigerator temperature (per thermometer on the outside of the walk-in refrigerator) was 36 degrees F.

Between 7:45 AM and 8 AM on October 14, 2010, a surveyor asked the cook about the size of the roast beef. A Dietary Supervisor responded that the weight of the roast beef was between 18 and 22 pounds.

The Dietary Director stated to a surveyor on October 14, 2010 between 8 AM and 8:30 AM that the afternoon cook who worked on October 13, 2010 was a part time cook. The afternoon cook who worked on October 13, 2010 was unavailable for an interview on October 14, 2010.

The morning cook was interviewed on October 14, 2010 at 1:15 PM. She stated the facility used an ice wand for cooling food like soups, and generally did not cut roasts as part of the cooling process. She stated all the facility cooks had food service experience prior to working in this facility.

The Food Service Manager was interviewed on October 14, 2010 between 1:30 PM and 2 PM. He stated he was aware there are regulations addressing timeliness of cooling food. He stated the facility did not use a cooling log to document temperatures of food while cooling.

The Dietary Director was interviewed on October 14, 2010 between 2 PM and 3 PM. He stated the roast beef that was cooked on October 13, 2010 was discarded.

In summary, the roast beef was not cooled in a timely manner in accordance with state regulations.

10NYCRR 415.14(h), 14-1.40(b)

Surveyor: Benedict, Patricia D
Based on observation, staff and resident interview, and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 5 residents reviewed with pressure ulcers (Resident #3), received the necessary care and services to prevent the deterioration of a pressure ulcer and promote its timely healing. Specifically, there was a significant delay in providing an alternating air mattress when the resident had a Stage II pressure ulcer; the facility did not develop and implement alternative preventative measures to implement when the alternating air mattress was not provided; did not ensure re-positioning measures were consistently implemented during survey; and did not ensure the interdisciplinary team, including the wound consultant, evaluated the effectiveness of the resident's care plan interventions, including her positioning schedule. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy as the resident's Stage II pressure ulcer deteriorated to a Stage III.
Findings include:

Resident #3 had diagnoses including dementia, morbid obesity, diabetes mellitus, and a history of skin breakdown on her coccyx.

On April 1, 2010 the resident's comprehensive care plan (CCP), was updated to reflect the resident had a Stage II pressure ulcer on her coccyx which resolved. The CCP documented the resident had potential for skin breakdown due to morbid obesity, non-ambulation, incontinence of bowel and bladder, pressure and diabetes. Interventions included to "inspect skin every shift"; cushion per physical therapy (PT) equipment; moisture barrier; turn and position every 2 hours; bariatric mattress; lubricate dry skin; PT/OT (occupational therapy) evaluation as needed for positioning equipment.

The resident was re-admitted to the facility on April 19, 2010 with a right fractured femur (thigh bone) and treatment with a leg brace. In the registered nurse (RN) readmission note, dated April 19, 2010 at 15:03 PM, there was no documentation that the resident had skin breakdown on her coccyx. Heel cushions were specified to be placed on the resident at that time.

On April 20, 2010, PT evaluation documented the resident required a Broda (specialized) chair "with tilt-recline" for "appropriate out of bed positioning" and she was dependent for mobility. The PT plan of care included a Broda chair, and a GEM (bariatric pressure-reducing) cushion.

On May 17, 2010, the "Skin Condition Report With Images" documented the resident had a "open lesion" on her coccyx, which measured 2.5 cm x 0.07 cm x 0.01 cm.

On May 19, 2010, the attending physician documented the resident had "a small coccyx lesion", was receiving "local wound care", and was transferred to a wheel chair with a Hoyer (mechanical) lift.

On May 27, 2010, the skin report documented the wound measured 4.0 cm x 3.5 cm x 0.2 cm. On June 2, 2010, the skin report specified the wound measured 3.5 cm x 1.0 cm and a surgical consult was conducted at the facility to evaluate the resident's wound.

On June 2, 2010, the surgical consultant documented the resident's coccyx area was assessed. Recommendations included: a Foley catheter, moisture barrier lotions to decrease moisture/urine irritation in the area, wet to dry dressing changes, a Tegaderm (a type of dressing) to cover the wound, and to continue offloading to reduce pressure to the area.

The "Skin Condition Report with Images" (dated June 16, 2010) documented the resident's coccyx Stage II was "now a pressure ulcer"; measured 4.0 cm x 1.5 cm x 0.2 cm; was "slightly larger"; was "not responding to treatment"; was seen by the surgical consultant; and new orders were obtained.

The June 16, 2010 surgical consultant documented the resident's pressure ulcer was debrided (unhealthy tissue removed). The consultant documented the resident "basically is from bed to wheelchair with Hoyer (mechanical) lift and needs several people to help when she does get moved because of her size." The plan was to "increase the protection to the area, by getting her a 'Gaymar type mattress', roll her over from side to side and avoid pressure to the area at all times."

On June 16, 2010, the resident's CCP, dated June 16, 2010, documented the resident had "actual alteration in skin integrity as evidenced by Stage II pressure ulcer on her coccyx. The plan included to "turn and position every 2-4 hours and as needed (reflected a change from the every 2 hour turn schedule from the "at risk for skin breakdown care plan)"; and prevent pressure to bony prominences."

At the follow-up surgical consult, (dated June 30, 2010), the physician documented the resident's Stage II pressure ulcer was 4 cm x 2 cm, and "approximately 0.5 cm deep". The surgeon specified staff were "trying to get (the resident) an alternating (air) mattress."

The "Skin Condition Report with Images", dated July 10, 2010, documented the resident's Stage II pressure ulcer measured 4.3 cm x 3.4 cm x 0.3 cm.

On July 14, 2010, the surgical consultant documented the resident was "basically bed ridden" and specified they were "waiting for the alternating air mattress to be available."

The attending physician progress note, dated July 14, 2010, documented the resident was "prone to pressure wounds due to morbid obesity and inactivity"; and noted her "coccyx pressure ulcer was managed" by a surgical consultant.

The "Skin Condition Report with Images", dated July 24, 2010, documented the resident's pressure ulcer was a Stage III, measured 5.0 cm x 3.2 cm x 0.3 cm; the wound bed was 50% slough (drainage covering the wound bed); and the resident was resistant to "being off her back". On July 29, 2010, the "Skin Condition Report with Images" documented the pressure ulcer was "about the same size and appearance."

On August 5, 2010, the pressure ulcer was documented on the "Skin Condition Report with Images" to measure 5.0 cm x 3.5 cm x 0.3 cm; with 50% slough; and specified the resident remained resistive to turning off her back.

The surgical consultant, on August 11, 2010, documented the resident's pressure ulcer measurements were 4.5 cm x 3.8 cm x 0.8 cm. The surgeon specified the resident was now on "an alternating air mattress and being changed from side to side constantly trying to offload pressure" on the pressure ulcer. The physician did not comment on the nursing notes that specified the resident's resistance to be positioned off her back. The consultant noted the resident was in a bed and "in a chair for meals." There was no documentation in the resident's medical record (including nursing notes, the CCP, the attending physician and consultant's notes) when the alternating air mattress was applied to the resident's bed.

The comprehensive care plan (CCP), dated September 1, 2010, documented the resident had a Stage III pressure ulcer. The CCP specified the resident had an alternating air bariatric mattress", used pressure relieving devices in her chair, was to be turned/positioned every 2 hours and as needed, and was to be repositioned in her chair as needed. There was no documented evidence when the resident's alternating air mattress was provided to the resident.

The resident's most recent Minimum Data Set (MDS) assessment, dated September 7, 2010, documented the resident's daily decision making skills were poor; she required cueing/supervision; and usually understood what others said. The MDS documented the resident was totally dependent on 2 staff for bed to chair transfers; had a Stage III pressure ulcer; was on a preventative program including pressure-relieving devices for her bed/chair; and was a turn/position program.

The resident's "Skin Condition Report with Images" documented the resident's Stage III pressure ulcer on September 24, 2010, measured 4.7 cm x 3.0 cm x 0.5 cm; with 70% granulation and 30% white slough.

On September 29, 2010, the resident's "Skin Condition Report with Images" documented the resident's Stage III pressure ulcer measured 4.5 cm x 3.5 cm x 0.5 cm (% of granulation and/or slough in wound bed not documented).

The resident's CCP, last reviewed by the interdisciplinary team on September 29, 2010, documented the resident was due to be seen by the surgical consultant. No revisions were documented regarding skin preventative measures at that time.

Review of the unit's Resident Care Assignment Sheet (a guide used by the certified nurse aide (CNA), updated on October 5, 2010), revealed the resident was to be turned and positioned "every 2 to 4 hours and as needed"; was to be "out of bed for meals only, back to bed after meals." The Resident Care Assignment Sheet was not updated to refect the revision to the resident's turning and positioning schedule as documented on the CCP to reposition the resident "every 2 hours".

On October 6, 2010, the resident's "Skin Condition Report with Images" documented the resident's Stage III pressure ulcer measured 5.0 cm x 3.3 cm x 0.5 cm, with 100% granulation.

On October 13, 2010 between 12:20 PM and 1:10 PM, the surveyor observed the resident seated upright in her wheel chair in the dining room. At 1:10 PM, the resident's visitor was heard to tell the licensed practical nurse (LPN) Unit Manager that the resident finished eating her lunch. At 1:25 PM, the same visitor was in the resident's room and told the surveyor the resident was still in the dining room. At 2:20 PM, the resident was alone as she watched TV and sat in her chair, alone in her room. At 3:15 PM, when the surveyor asked the resident how her afternoon was, the resident told the surveyor that she wanted to go back to bed.

As observations continued on October 13, 2010 at 3:25 PM, the resident sat upright in her chair when a CNA left linen on top of the resident's cabinet near her door. At 3:40 PM, the surveyor observed a registered nurse (RN) reposition the resident's oxygen nasal canula. At 3:45 PM, the surveyor observed a CNA go into the resident's room. Facility staff were not observed offering to transfer the resident back to bed before supper.

At 4:00 PM on October 13, 2010, the surveyor continued observations of the resident as she remained seated upright in her chair in her room after the LPN administered her medications. At 4:40 PM, the resident sat in her room watching television. At 4:45 PM, a CNA wheeled the resident to the dining room. Between 5:15 PM and 6:10 PM, the resident sat in the dining room in her chair; and at 6:15 PM, the resident sat in her chair in her room.

During all the observations between 12:20 PM and 6:15 PM on October 13, 2010, the surveyor observed the resident to be seated upright in her chair, without a change in position during that time.

On October 14, 2010 at 1:20 PM, the surveyor interviewed the CNA who was assigned to care for the resident on October 13, 2010 from 7 AM to 3 PM. The CNA stated the resident refused to go back to bed after lunch. She stated she transferred the resident "briefly" to bed to provide personal hygiene care, and returned her to her chair. The CNA said she notified the LPN Assistant Unit Manager or the LPN Unit Manager after the resident refused care.

On October 14, 2010, the LPN Assistant Unit Manager was interviewed at 1:30 PM, and the LPN Unit Manager was interviewed at 1:40 PM. During these interviews, both LPNs stated they had no knowledge the resident refused to return to bed after lunch on October 13, 2010.

When requested, the facility could not provide documentation the resident refused to return to bed after lunch on October 13, 2010.

On October 14, 2010 at 11 AM, the surveyor requested the resident's permission to observe her Stage III coccyx pressure ulcer treatment. The resident refused to allow this observation.

In summary, the facility:
- delayed the provision of an alternating air mattress for more than 1 month for the resident with a Stage II pressure ulcer, after it was recommended by the surgical consultant;
- did not develop and implement alternative preventative measures when there was a significant delay in providing an alternating air mattress;
- did not consistently implement the preventative plan of care for assisting the resident back to bed after her noon meal;
- did not re-position the resident every 2 hours during survey to assist with offloading pressure as planned;
- did not ensure the CNA assignment sheet was updated to reflect the turning and positioning plan documented on the resident's CCP.

10NYCRR 415.12 (C)(1-2)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not provide services that met professional standards of quality for 1 of 9 current sampled residents (Resident #7). Specifically, a physician telephone order for Resident #7's pressure ulcer treatment was not written after it was received, and the treatment was not entered on the treatment administration record in a timely manner. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #7 had diagnoses of Parkinson's disease, congestive heart failure, peripheral edema, and severe arthritis.

The Minimum Data Set (MDS) assessment, dated March 10, 2010, documented the resident had short and long term memory problems, and modified independence in decision making skills.

A nursing note (dated July 20, 2010) documented the resident was found with a fluid filled blister on the inner aspect of the right thigh, near the brief line. The area was cleaned and patted dry, and the brief was left unfastened.

The comprehensive care plan (CCP), dated August 31, 2010, documented the resident had a potential for impaired skin integrity due to non-ambulatory status. Interventions included a pressure relieving mattress and a pressure relieving chair cushion.

A nursing note dated (October 13, 2010 at 8:33 AM) documented the resident was noted with bilateral fluid filled blisters on the inner thighs. An order was obtained to apply Skin Prep, cover with Opsite (a type of dressing) and change every 3 days until resolved.

On October 14, 2010 at 11:50 PM, the resident's physician orders and treatment administration record (TAR) were reviewed and revealed no documented order for the treatment of the blisters; no treatment was documented on the TAR.

The licensed practical nurse (LPN) Assistant Unit Manager was interviewed on October 14, 2010 at 11:50 AM. He stated an order should be documented in the physician telephone orders and then put in the TAR. He stated "the area was not recorded in the TAR book yet."

The registered nurse (RN) who wrote the progress note on October 13, 2010 was interviewed on October 14, 2010 at 12:22 PM. She stated she took the verbal order over the telephone from the physician, but did not write the order, because she "got busy."

The treatment LPN was interviewed on October 14, 2010 at 1:15 PM. She stated she was not aware the resident was to have a treatment for blisters.

In summary, the physician order for the resident's pressure ulcer treatment was not documented in a timely manner, in the physician orders and treatment administration record.

10NYCRR 415.11(c)(3)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the main outside control valve for the sprinkler system water supply (post indicator valve) was electrically supervised. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

When the surveyor observed the post indicator valve on October 14, 2010 at 12:05 PM, the valve was open, locked, and unsupervised.

Review of the contract company's inspection reports of the facility sprinkler system, (dated June 14, 2010 and September 10, 2010) revealed documentation that the post indicator valve was not supervised.

When the Plant Operations Director was interviewed on October 14, 2010 at 12:15 PM, he stated he was not sure who had access to the numeric combination to unlock the padlock on the post indicator valve.

In summary, the post indicator valve was not electrically supervised, as required.

10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 of 15 tested resident room doors (Resident room #111) latched properly to keep it closed; and did not ensure its timely repair. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The corridor door to resident room #111 was tested at least 3 times on October 13, 2010 at 3:30 PM and the door did not latch each time. The surveyor observed the door latch did not line up with the strike plate (where the latch engages).

The Room Door Monthly Operation Verification form for September (2010) documented resident room doors were checked on September 22, 2010. The form documented the corridor door to resident room #111 was not operating properly (no documented reason). There was no documentation in the column on the form titled "action taken" next to room #111.

When the Plant Operations Director was interviewed on October 14, 2010 between 11 AM and 1 PM, he stated he was not able to find a work order to repair the door; he said the maintenance staff member directly responsible was unavailable to be interviewed.

In summary, the corridor door to resident room #111 did not have an acceptable means of keeping the door closed, and was not repaired in a timely manner.

10NYCRR 415.29(a)(1&2), 711.2(a)(1)