Table of Contents
Dr William O Benenson Rehab Pavilion
Deficiency Details, Certification Survey, November 16, 2009
PFI: 7298
Regional Office: MARO--New York City Area
F334 483.25(n): INFLUENZA AND PNEUMOCOCCAL IMMUNIZATION
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: January 11, 2010
The facility must develop policies and procedures that ensure that -- (i) Before offering the influenza immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. The facility must develop policies and procedures that ensure that -- (i) Before offering the pneumococcal immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicated, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. (v) As an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's legal representative refuses the second immunization.
Citation date: November 16, 2009
Based on observations, record reviews, and staff interviews, the facility did not ensure that the residents and/or their designated representatives received education regarding the benefits and potential side effects prior to the administering of the influenza vaccine. This was evident for six (6) of thirty (30) sampled residents. (Residents #2, #4, #7, #11, #13, and #17)
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are but not limited to:
1) Resident #11 is a 63 year old male with the diagnoses including Diabetes Mellitus, Anemia, Hypertension, and Schizophrenia.
The Minimum Data Set (MDS) 2.0 Assessment dated 10/9/09 documented that this resident has cognition with modified independence.
The immunization record documented that the resident received Influenza vaccine on 10/7/09. There was no documented evidence that either the family or the resident received education regarding the benefits and potential side effects prior to the administration of the influenza vaccine.
The nursing progress note dated 10/7/09 documented that the flu vaccine was given on this day and there was no documented evidence that education on the flu vaccination was given.
The Registered Charge Nurse (R.N.) was interviewed on 11/13/09 at 10:55 a.m., and stated that the resident was educated but she was unable to provide any documented evidence.
2) Resident #17 is a 68 year old female with diagnoses which include: Chronic Obstructive Pulmonary Disease, Dysphasia, Hypothyroidism, and history of Breast Cancer.
The Minimum Data Set (MDS) dated 8/17/09 documented the resident as independent in cognition and daily decision making ability.
The resident's immunization record documented that the resident received an influenza vaccination in the facility on 10/12/09. There is no documented evidence that the resident received education regarding the risks and benefits prior to receiving the vaccination.
On 11/12/09 at approximately 12:15 p.m., the Registered Professional Nurse (RN) who administered the vaccination on the unit was interviewed. She stated that as per facility policy, she always educates residents, and/or family of residents about the risks and benefits prior to administering the vaccine. She stated that she does not document this in the resident's record. According to the RN, she was not aware that she is required to document education. The RN stated that she knows that she must document refusal, and contraindications, pre and post monitoring of vital signs, and that the vaccination was given.
The resident was interviewed on 11/12/09 at 12: 30 p.m. She stated that the nurse did explain the risks and benefits of the influenza vaccination prior to administering it to her, and she gave her consent to receive the vaccination.
The Director of Nursing was interviewed on 11/16/09 at 11:30 a.m. She stated that when consent is obtained from the family members or the resident, the risks and benefits of the vaccination are explained at that time and documented. When asked to elaborate on the documentation requirement, she only stated that the Department of Health Guidelines are followed as required.
The Medical Director was interviewed on 11/16/09. He stated that according to the policy and procedures, the staff should be documenting the contraindications, and refusal of vaccinations. He stated that it is the responsibility of the nurses to provide education to the resident's and or their designated health representative regarding the vaccinations risks and benefits. He stated that they should document refusals, contraindications of the vaccination, that the vaccine was administered, as well as education. He stated that the attending physician can also provide education to the resident and or families. The Medical Director stated that he also provides education, however, his focus has been on ensuring that the staff receives the flu vaccination this season.
415.12
F253 483.15(h)(2): HOUSEKEEPING AND MAINTENANCE SERVICES
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: January 11, 2010
The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Citation date: November 16, 2009
Based on observations, and staff interview, the facility did not ensure that the residents' care equipment are maintained in a sanitary and clean condition. This was evident for three (3) of eight (8) resident care units. (Units #7, #8, and #9)
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are:
1) During the initial tour of the Ninth (9th) Floor unit on 11/10/09 at 10:10 a.m.,
the suction machine in the Dining Room was observed with built up, white lint like dust particles fully covering the top and the base of the pump, the canister, and on the table beneath the pump.
On 11/10/09 at 11:30 a.m., the Licensed Practical Nurse (LPN) was interviewed and stated that the housekeeping staff cleans the suction machine and the table. The LPN further stated that the nurses check the machine every shift for operation and supply, and that she checked this morning but did not see the dust.
415.5(h)(3)
2) On 11/10/09, during the general tour of the Seventh (7th) Floor with the Nursing supervisor, a tube feeding pump (Room #703) was observed with a small round tan stain on the right top of the pump, two (2) drip stains on the right side, and 1 drip stain on the right side behind the dial. The Nursing Supervisor was interviewed and stated that the nurses are responsible to clean it.
On 11/12/09 at 12 noon, the tube feeding pump was again observed and noted to have the same stains.
3) On 11/10/09, during a general tour of the Eighth (8th) Floor with the Nursing Supervisor, one feeding pump (Room # 817B) was noted to have white stains on the top right side, back, knob, and on the IV pole base. A second (2nd) feeding pump (Room # 819A) was also observed to have brown stains on the knob, and right side of the pump.
On 11/10/09 at approximately 10:43 a.m., the Nursing Supervisor for the Eighth (8th) Floor was interviewed and stated that nursing is responsible to clean the pump daily, and Housekeeping cleans the poles weekly.
On 11/12/09 at 12:15 p.m., the Registered Charge Nurse (RN), of 7AM-3PM shift on the 7th Floor, was interviewed and stated that he checks pumps and notifies housekeeping to clean. The RN looked at the pump with the State Surveyor (SA) and viewed the stains on the feeding pump. He stated: "I will call housekeeping to clean it."
On 11/12/09 at 3:35 p.m., the Housekeeping Director was interviewed regarding cleaning the tube feeding pumps and Intravenous (IV) poles. He stated the poles and walls are the responsibility of Housekeeping and they are cleaned daily, and that he monitors this during his daily rounds.
On 11/12/09 at 3:48 p.m., the 7th Floor Nursing Supervisor and the State Surveyor checked at the tube feeding pump. The nursing supervisor saw the spots and drips on the right top, and the drip mark behind the dial. She stated: "That's Housekeeping." The SA repeated to her what the Housekeeping Director stated that they do poles and walls only. The nursing supervisor stated: "Oh, I see."
On 11/13/09 at 12 noon, a follow up of the tube feeding pump on the 7th Floor was done and the tube feeding pump was observed to be clean.
415.5(h)(2)
Z200 415.18: PHARMACY SERVICES
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: Not Available
Citation date: November 16, 2009
epn CFR STATE DEFICIENCIES ONLY
415.18 Pharmacy Services
Storage of drugs and biologicals
The facility shall store all drugs and biologicals in locked compartments under proper temperature controls, and permit access only to authorized personnel.
The facility shall provide separately locked, permanently affixed compartments for storage of controlled drugs and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stores is minimal and a missing dose can be readily detected. Storage of controlled substances shall be in accordance with Article 33 of the Public Health Law and Part 80 of this Title.
Poisons and medications for " external use only " shall be kept in a locked cabinet and separate from other medications; and
Medications whose shelf life has expired or which otherwise no longer in use shall be disposed of or destroyed in accordance with State and Federal law and regulations.
This Regulation was not met as evidenced by:
Based on observation, and staff interview, the facility did not ensure that a vial of opened Regular Insulin was dated. This was evident in one (1) of eight (8) resident care units. (8th Floor)
This resulted in no actual harm with potential for more than minimal harm.
The findings are:
On 11/10/09 during the general tour of Unit #8 with the Licensed Practical Nurse (LPN)/Charge Nurse, an undated and opened bottle of Regular Insulin was found in the medication unit refrigerator.
The LPN was interviewed on 11/10/09 and stated that she did not know who opened the vial and that there were no initials on the vial.
F463 483.70(f): RESIDENT CALL SYSTEM
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: December 31, 2009
The nurses' station must be equipped to receive resident calls through a communication system from resident rooms; and toilet and bathing facilities.
Citation date: November 16, 2009
Based on observation, and staff interview, the facility did not ensure that the communication system, including the call bell alarm system, was functional. Specifically, the light above Room 804 did not light when the alarm was activated. This was evident in one (1) of eight (8) nursing care units. (Eight (8) Floor)
This resulted in no harm with potential for more than minimal harm that is not immediate jeopardy.
The finding is:
On 11/10/09, the general tour of the Eight Floor was conducted with the Charge Nurse. The call bell was tested from both A and B beds and it was observed that the light over the doorway did not light up. The call bell did ring, the light at the nurses' station was on, and staff member responded. When the staff got to the corridor, he was unable to identify which room the call was coming from. He stated, "I don't know which room it is. There is no light." The staff from the nurse's desk was observed to call out "804!" The Charge Nurse immediately called Maintenance to report the situation.
On 11/10/09 at 12:20 p.m., the Maintenance staff was observed working on the light over the doorway of the affected room.
On 11/16/09 at 12:05 p.m., the lights over the doorway was observed not working, it lights and rings at the nurse's desk.
On 11/16/09 at 12:11 p.m., the Director of Maintenance was interviewed over the phone and was asked about the progress of the repairs to the call bell lights. He said that the company was called last week to repair the call bell but they were very busy and were coming that day.
On 11/16/09 at approximately 1:30 p.m., the Director of Maintenance came to the Library (conference room) and stated that the lights were repaired.
415.29
F281 483.20(k)(3)(i): SERVICES PROVIDED MEET PROFESSIONAL STANDARDS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: January 11, 2010
The services provided or arranged by the facility must meet professional standards of quality.
Citation date: November 16, 2009
Based on observations, and staff interviews, the facility did not ensure that the services provided met professional standards of quality. Specifically, the facility did not ensure that an opened vial Regular Insulin was dated (Unit #8); and the water bags that hang with tube feedings were changed in accordance with professional standards. This was evident for one (1) of eight (8) resident care units (Unit #8).
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are:
1) On 11/10/09, during the general tour of unit #8th Floor with the Licensed Practical Nurse (LPN)/Charge Nurse, an undated and opened vial of Regular Insulin was observed in the medication refrigerator. The LPN/Charge Nurse stated that she did not know who opened the vial, and that there were no initials written on the vial.
2) On 11/10/09, during the general tour of the unit #7th floor with the nursing supervisor, water bags, connected to tube feedings and hanging from the IV pole dated 11/08/09, were observed in two residents' rooms who were tube fed, including Resident #3.
On 11/10/09 at 12:10 p.m., the LPN/Charge Nurse was interviewed and stated that her role regarding the tube feedings is: "To make rounds, make sure they (feedings) are going. The evening shift staff changes tube feedings. The water bag should be changed every day." The LPN also stated that she knew that the bags were outdated. When asked why she did not change them, the LPN/Charge Nurse stated "Things got busy." She was asked if she told anyone about the bags, she stated that she didn't call anyone to change them. The LPN was asked what the implication of not changing the tube feeding bags and she stated: "Infection. Definitely, once a day need to be changed."
On 11/12/09 at approximately 3 p.m., the Education Coordinator/Registered Nurse (RN) was interviewed regarding the procedure of hanging the tube feedings and water bags. She stated: "The tube feedings are put up by evening shift every evening at 5 p.m., both water and tube feeding. Tubing is changed every 24 hours, feeding is good for 48 hours. Water is changed daily with tubing which includes the bag and Y-set." She was asked when is inservice done. She stated that inservice is done yearly and the last inservice was in September covering infection control and procedures to hang the tube feeding.
415.11(c)(3)(i)