Bishop Henry B. Hucles Episcopal Nursing Home

Deficiency Details, Certification Survey, December 30, 2010

PFI: 7069
Regional Office: MARO--New York City Area

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F248 483.15(f)(1): ACTIVITY PROGRAM MEETS INDIVIDUAL NEEDS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: February 25, 2011

The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

Citation date: December 30, 2010

Based on observations, record reviews and staff interviews, the facility did not ensure that there was an ongoing program of activities developed for the dementia unit. This was evident for 1 of 30 sampled residents. Resident #13 .

This resulted in no actual harm with potential for more than minimum harm that is not immediate jeopardy.

The finding is:

Resident #13 is an 89 years old male admitted to the facility with diagnoses that include Dementia, Coronary Arthrosclerosis Disease, Hypertension, Parkinson's Disease, Syncope, Seizure Disorder and Acute Gastritis. This resident resides on the dementia unit.

The MDS (minimum data set) assessment 3.0 dated 11/29/2010 identified the resident as severely impaired with cognition, completely dependant on staff for all his activities of daily living.

On 12/22/2010 at 2:30 PM, the resident was observed in the dining room seated with 3 residents at a table. The 3 residents were asleep. The television was on. This table was 80 feet away from the television.
There were 25 residents observed in the dining room. There was no activity being conducted by the three CNAs who were in the dining room.

On 12/22/10 at 3:20 PM, the TV volume was turned down and music was played. A CNA (certified nursing assistant) was playing with a puzzle with one resident and 1 resident had a puzzle in front of her but was not touching it. Another CNA came into the dining room and began to serve nourishment and snacks to the residents.

The December, 2010 activities calendar documented the following activities for 12/22/10: 11:00 AM -- Chapel and at 2:30 PM "Resident Christmas Choir Sing A Long" on the 7th floor.

During an interview on 12/22/10 at 3:30PM, a CNA stated that she was responsible for monitoring the residents in the dining room. She further stated there are no activities in the afternoon. The residents are to stay in the dining room until after dinner and then the residents are prepared for bed.

The activities calendar for 12/23/10 documented that at 11:00AM -- "The Price is Right" (no unit designated) and at 2:30 PM - Resident Christmas party on the 3rd Floor.

On 12/23/2010 at 10:00 AM, resident #13 was observed in the dining room asleep. Seven of the 23 residents in the dining room were observed sleeping. The television was off and the radio was playing music. There was one CNA in the dining room. There was no staff interaction with the residents in the dining room. The CNA assigned to the unit was serving nourishment and snacks to the residents. The recreation leader came into the dining room at 11:00 AM and gave the residents sheets of paper and crayons. The recreation leader sat with 3 residents and assisted the residents with their puzzles. At 11:45 AM, the CNAs started preparing the residents for lunch.

The recreational leader was interviewed immediately after the observation and stated that she is responsible to cover the other units and also has to prepare for the upcoming afternoon party.

The comprehensive care plan for activity pursuit patterns dated 9/1010 and revised 12/7/10 documented that the "...Resident need redirection and cueing during activities ...Enjoy music programs, TV shows and movies..." This plan further documented to " Bring the Resident to activities programs ..."

The December, 2010 activity calendar documented that for the second floor dementia unit, there were 10 of 31 days with planned activities and there were no planned activities after 2:30pm.

The Activity Director and the Administrator were interviewed on 12/23/10 at 4pm and stated that they are aware of the lack of activities on the dementia unit and are in the process of hiring additional activity staff.

415.5(f)(1)

F371 483.35(i): STORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: January 31, 2011

The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Citation date: December 30, 2010

Based on observation and interview, it was determined that the facility did not ensure that food was served and distributed under sanitary conditions. Reference is made to the dishwashing machine not reaching the hot water temperatures required for the sanitization of utensils as per manufacturer's specifications.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the annual survey conducted on 12/22/10 between 9:15 a.m. and 11:00 a.m. it was observed that the dishwashing machine final rinse gauge was not attaining the required temperature for the purpose of sanitization. The manufacture's specifications state that the final rinse temperature should be 180 Fahrenheit (F). However, numerous observations of the dishwasher machine in operation revealed that the final rinse cycle gauge indicated temperatures ranging only between 140 and 150 degrees F. It was also noted that there was no back up sanitizer being used.

In an interview on 12/22/10 at approximately 9:45 a.m., the Dietary Supervisor stated that the machine had been working fine the previous day. She indicated that staff usually monitor the temperatures daily and that a log is maintained for each dishwashing cycle. Review of the dishwashing logs revealed that temperatures were last recorded two days ago, on 12/19/10, and that the final rinse temperature was 180 degrees. When asked why there was a gap in the log, the Dietary Supervisor stated that the aide operating the dishwashing machine might have forgotten to write in the temperatures.

The Dietary Supervisor indicated that she would contact the dishwasher repair company, and that in the interim, all utensils would be washed in the 3-compartment sink until the dishwashing machine was fixed.

NYCRR 415.14(h)
Chapter 1 SSC Subpart 14-1

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 25, 2011

The facility must 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. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Citation date: December 30, 2010

Based on observation and staff interview, the facility did not ensure that infection control standards were maintained. Specifically, handwashing standards were not maintained during wound care and wound assessment. This was evident for 1 of 30 sampled residents (Resident #4).

This resulted in no actual harm with potential for more than minimal harm.

The finding is:

Resident #4 is an 87-year-old with diagnoses which include Diabetes and Left Lateral Leg Ulcer.

The Minimum Data Set 2.0 Assessment dated 9/17/10 documented that the resident had short-term memory problems and moderately impaired cognition.

During a wound care observation of the left leg ulcer on 12/23/10 at approximately 9:10 AM, the Licensed Practical Nurse (LPN) was observed cleansing the wound and then applied the treatment and clean gauze sponge to the wound directly after without washing her hands. The LPN then washed her hands and changed gloves and put a self-adhesive pad on top of the dressing applied.

The LPN was interviewed on 12/23/10 at 9:45 AM and stated that she should wash her hands and don new gloves prior to the dressing change, after removing the soiled dressing, and after cleansing the wound. The LPN further stated that she thought she had washed her hands before applying the treatment and new dressing.

415.19(a)(1-3)

F166 483.10(f)(2): FACILITY RESOLVES RESIDENT GRIEVANCES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 25, 2011

A resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

Citation date: December 30, 2010

Based on resident interview, record review, and staff interviews, the facility did not ensure that prompt efforts were made to resolve a resident's grievance. This was evident for 1 of 30 sampled residents (Resident #20).

This resulted in no actual harm with potential for more than minimal harm.

The finding is:

Resident #20 is a 70-year-old with diagnoses which include: Breast Cancer, Hypertension, and Insulin Dependent Diabetes Mellitus.

The Minimum Data Set 3.0 dated 10/14/10 documented that the resident has intact cognition and no behavioral symptoms.

The resident was interviewed on 12/30/10 at 11:15am and stated that she had clothes missing since 10/2009 (3 pairs of pants and 3 shirts), and she filled out forms regarding the missing clothing with the Environmental Associate. She further stated that she gave a copy of the forms to her Social Worker, who told her that Social Work does not normally receive the forms regarding missing clothing. The resident also stated that the Director of Environmental Services told her that he would come to look in her closet for the clothing 2 or 3 times, but he never came. Resident said she never received a resolution.

The Resident Council Minutes dated 1/29/10 documented: "(resident #20) did claim to be missing five (5) pairs of pants. ACTION: (Director of Environmental Services) made aware...(resident #20) added more missing items to her list, saying she reported it to housekeeping two (2) months ago...She said she has five (5) blouses..now she's missing three (3)."

The Resident Council Minutes dated 2/19/10 documented that the laundry claims nothing is missing and the Director of Environmental Services will visit the resident to review.

The Resident Council Minutes dated 5/21/10 documented: "(Resident #20) complained about her missing clothes. She said even though she reports them missing, she still does not get them back. ACTION: (Director of Recreation) will review a missing clothing plan of action with Director of Laundry Services (Director of Environmental Services)".

The Resident Council Minutes dated 7/2/10 documented that the Director of Environmental Services discussed a new investigative system that was being developed to track missing items in response to the resident's grievances.

There was no documented evidence in the resident's chart or the facility grievances that the resident's grievance about missing clothing was investigated and resolved.

The Social Worker was interviewed on 12/29/10 at 2:50pm and stated that the resident mentioned missing clothes over 3 months ago and said she would let the SW know if they were not in the laundry. The SW continued to say that the resident never came to her to fill out a grievance. She further stated that the Social Work Director usually received a copy of the Resident Council Minutes and informed the staff if any of their assigned residents expressed grievances. The SW also stated that she was not aware of the resident's grievances in Resident Council and currently there is no Social Work Director to receive the minutes.

The Environmental Associate (EA) was interviewed on 12/30/10 at 12:30pm and stated that he remembers speaking to the resident about missing clothing about 6 months ago or more. He further stated the resident completed the missing clothing investigation form with the unit Registered Nurse Supervisor who forwarded it to the Director of Environmental Services (DES). He also stated that he was given the form by the DES to complete the investigation and he believes he found 3 pants and 2 shirts. The EA stated that there was a problem with the clothing not being labeled, and the property sheets did not match what was missing. He said he discussed his findings with the resident, and the DES takes the results of the investigation and discusses it with the Administrator to determine if residents will be reimbursed.

The DES was interviewed on 12/30/10 at 1:00pm and stated that he could not find the investigation for the resident's missing clothing, but he discussed it with the resident. He said the resident was told that some of her clothing was found, but he will look at the next shipment of laundry. The DES further stated that he never followed up with the resident about the missing clothing, assuming she had them because he heard no further complaints.

The Director of Recreation was interviewed on 12/30/10 at 2:29pm and stated that she spoke to the DES about missing clothing and he said he was working on the process. She further stated that once someone speaks to the resident about an issue, if it does not come up anymore it is considered addressed.

415.3(c)(1)(ii)

F250 483.15(g)(1): MEDICALLY RELATED SOCIAL SERVICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 25, 2011

The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: December 30, 2010

The facility did not ensure that medically-related social services were provided to maintain the highest physical, mental, and psychosocial well-being of each resident. Specifically, advance directives were not reviewed, nor was contact attempted, with the designated representative of an impaired resident. This was evident for 1 of 30 sampled residents (Resident #24).

This resulted in no actual harm with potential for more than minimal harm.

The finding is:

Resident #24 is a 25-year-old with diagnoses which include Cerebral Palsy, Mental Retardation, and Seizure Disorder. The resident had re-admissions to the facility on 6/1/10 and and 7/6/10 after hospitalizations.

The Minimum Data Set 3.0 Assessment (MDS) dated 10/10/10 documented that the resident has long and short-term memory problems and severely impaired cognition. The resident requires total care with all activities of daily living.

The "Advance Directives Follow-up Reviews" dated 7/21/09 documented: "Resident/Family refused Advance Directive implementation" and "Resident/Family refused DNR [Do Not Resuscitate] implementation".

The "Advance Directives Follow-up Reviews" dated 10/22/09, 1/19/10, 4/16/10, and 7/19/10 documented: "Resident's cognitive deficit impedes initiating Advance Directive" and "Resident's cognitive impairment impedes decision making ability to sign DNR request".

The Social Work quarterly assessment dated 7/17/09 documented that the resident was evaluated for community placement by an organization but it was determined that he was not suitable.

There was no documented evidence in the medical record that the social worker made any contact with the resident's designated representative from 7/17/09 to 12/30/10 to discuss placement options or advance directives.

The Social Worker was interviewed on 12/30/10 at 3:15pm and stated that the advance directives are reviewed quarterly at the Comprehensive Care Plan (CCP) meeting, which families are invited to by mail. She further stated that there was no protocol for the social worker regarding how often families are called to review advance directives if they do not attend the CCP meeting. She also stated that the family is not called for re-admission or discharge/transfer, and the social worker is required to send bed hold information via mail.

The facility policy for "Advance Directive Follow-up Review Documentation" dated 2/3/03 documented: "...a discussion regarding Advance Directive and Do Not Resuscitate (DNR) will take place upon admission, and quarterly...Social Worker will document quarterly discussion with resident and designated representative decision regarding Advance Directive and Do Not Resuscitate (DNR)".

415.5(g)(1)(i-xv)

F328 483.25(k): PROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 25, 2011

The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses.

Citation date: December 30, 2010

Based on observation, record review and staff interviews, the facility did not ensure that a resident received tracheostomy care as ordered. This was evident for 1 of 30 sampled residents (#14)

This resulted in no harm with potential for more than minimal harm.

The findings are:

Resident # 14 was admitted to the facility on 4/1/10 with diagnoses including Stage 4 Laryngeal Cancer, Seizures and Asthma. The MDS (minimum data set) 3.0 assessment dated 10/6/10 documented that the resident was cognitively intact and required extensive assistance of 1 person for hygiene needs. The MDS also documented that the resident had a contracture to the neck on 1 side.

The resident was observed in his room during initial tour on 12/22/10 at 11:20 AM. The resident was breathing via tracheostomy with no supplemental oxygen. A gauze dressing was observed to the left side of the resident's neck with brown drainage on the lower edge next to the resident's tracheostomy. There was a foul odor noted upon approaching the resident. The resident was again observed in his room on 12/23/10 at 12:15 PM and a foul odor was present. The resident was observed in his room on 12/29/10 at 12:20 PM. He was interviewed at that time and stated that "the neck stinks, I asked the nurse a long time ago to change it for me, I am still waiting".

A dressing change to the resident's neck wound was observed on 12/29/10 at 12:45 PM. The wound was approximately 8 cm long with malodorous serosanguinous drainage . There was a marked decrease of the odor after the dressing change was completed.

The Physicians' orders dated 11/30/10 documented "cleanse neck ulcer.......apply Bactroban BID (twice per day)" and tracheostomy care every shift. Physician's orders dated 12/28/10 included: "discontinue treatment to L (left) neck ulcer BID, cleanse L (left) neck ulcer ...apply Bactroban Q (every) shift.

The resident's treatment records for December 2010 revealed no documented evidence that tracheostomy care was transcribed.

An interview was conducted with the resident's nurse on 12/29/10 at 12:30 PM. She stated that the trach care was done every day, but the resident did not like to be suctioned. She further stated she was not aware of the resident cleaning the trach canula himself. She also stated that she was not sure why the trach and wound treatments were not documented.

415.12(k)(5)(4)

F282 483.20(k)(3)(ii): SERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 25, 2011

The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Citation date: December 30, 2010

Based on observation, record review and staff interviews, the facility did not ensure that medication was administered as per physician's order. This was evident for 1 of 30 sampled residents. Resident # 31.

This resulted in no harm with potential for more than minimal harm .

The finding is:

Resident #31 is a 79 year old male admitted to the facility with diagnoses of Hepatitis, Diabetes Mellitus, Anemia, Pacemaker, Bradycardia and Alzheimer's Disease.

During a medication pass observation on 12/29/2010 at 10:30 AM , the Licensed Practical Nurse (LPN) was observed administering
Prandin 0.5 milligram to the resident.

The physician's order dated 12/11/2010 documented Prandil 0.5 mg (milligrams) 1 tablet by mouth twice daily with meals and hold if the patient does not eat.

The MAR (medication administration record) dated 12/11/10 documented that Prandil is to be administered at 7:30 AM for the am dose and 4:30 PM for the PM dose.

The meal time for the unit documented that breakfast is served at 8:00 AM.

The LPN was immediately interviewed after the administration of the medication and stated " it is clear that the blister pack and the physician's order is to give the medication with meals and it was transcribed inaccurately... I signed at 7:30 AM as transcribed in the MAR even though I gave it with the rest of his medications".

415.11(c)(3)(ii)

K21 NFPA 101: DOORS IN FIRE AND SMOKE PARTITIONS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 30, 2010

Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure is held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of: a) the required manual fire alarm system; b) local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and c) the automatic sprinkler system, if installed. 19.2.2.2.6, 7.2.1.8.2

Citation date: December 30, 2010

Based on observation and interview, it was determined that the facility did not ensure that the emergency exit door was held open only by a device arranged to automatically close the door upon the activation of the fire alarm system. Reference is made to the emergency exit door in the lobby area that was noted to be held open with a garbage container, and, although it was equipped with a self-closing device, it did not positively latch within its frame, preventing the door alarm from fully engaging.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are:
During the annual survey on 12/22/10 at approximately 8:40 am it was noted that the emergency exit discharging to the side of the parking lot was held open with a 32-gallon garbage can. At approximately 8:45 am on 12/23/10 it was noted that, although this door was in the 'closed' position, the door did not positively latch in its frame. As a result, neither the lock nor the door alarm system were engaged. The door was immediately closed by the Director of Environmental Services. At approximately 9:45 am the alarm system was tested and was observed to be functioning. However, it was noted that the door's self closing mechanism was preventing the door from positively latching within its frame.
In an interview with the Director of Environmental Services at approximately 10:00 a.m. on 12/23/10, he stated that the self closing mechanism on the door would be fixed immediately to ensure that the door latches properly. He also stated that all staff would be in-serviced in regards to keeping the emergency exit door closed and the alarm system engaged at all times.
711.2(a)(1)

K61 NFPA 101: MAIN SPRINKLER CONTROL

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: February 8, 2011

Required automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed. NFPA 72, 9.7.2.1

Citation date: December 30, 2010

Based on observation and interview, it was determined that the facility did not ensure that the sprinkler control valves, located on each floor landing within exit stair case B, were identified with signage indicating the portion of the system each valve controls.
This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

The findings include:

During the annual LSC survey conducted on 12/22/10 and 12/23/10 between 9:30am and 3:00pm, the facility was observed to be protected with an automatic sprinkler extinguishing system. It was also observed that sectional sprinkler valves are located on each floor landing of stair case B, from the 2nd to the 7th floor stair case landing. These sectional sprinkler valves were not identified and/or provided with signage indicating the portion of the system they control.

In an interview on 12/23/10 at approximately 11:00am, the Director of Environmental services stated that the sprinkler control valves are located on each floor landing of stair case B, from the basement level to the 7th floor. He added that he was unaware of this code requirement and that he will ensure that the required identifying signage is provided.

711.2 (a)(1)