Park Avenue Extended Care Facility

Based on record review and staff interviews during the recertification survey, the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health. This was evident for 1 of 7 Gastrostomy Tube (GT) (a tube surgically inserted into the stomach to provided nutrition and hydration) fed residents reviewed for hydration in a total of 30 sampled residents (Resident #8). Specifically, Resident #8 had physician's orders dated 2/4/10 and 2/10/10 for extra water via the GT. There was no documented evidence in the medical record that the extra fluid had been administered as per the physicians orders. On 2/15/10, eleven days after the additional fluids had first been ordered, Resident #8 was transferred to the hospital with a diagnosis of Electrolyte Imbalance (a condition wherein there is either too much or too little sodium and potassium in the body fluid, tissue and blood). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The finding is:
Resident #8 was readmitted to the facility on 2/4/10 after a hospitalization for Chronic Obstructive Pulmonary Disease (COPD). The resident was readmitted with diagnoses that included Senile Dementia, Dysphagia (difficulty swallowing), Congestive Heart Failure (CHF) and Pressure Ulcers (P/Us). The resident was also documented as being fed via a GT and was to receive Nothing by Mouth (NPO)
The electronic physician's order dated 2/4/10 at 5:16 PM documented the following GT feeding order: Osmolite 1.2 1000 cubic centimeters (cc)/day, starting at 5:30 PM until completed, at 70 cc/hour with a 250 cc water flush before and after feeding. The GT order included for the resident to received 30 cc of water before and after medication passes and 10 cc of water to dissolve each medication and 10 cc between each medication. An additional order was documented for the resident to received 250 cc of extra water via the GT every shift at 6:00 AM, 2:00 PM, and 10:00 PM.
The Comprehensive Care Plan (CCP) developed for dehydration dated 2/5/10 documented that the resident was at risk for dehydration secondary to being on diuretic therapy, and receiving a GT feeding. The CCP also documented that the resident will be free from signs and symptoms (s/s) of dehydration for 90 days. The CCP documented the following interventions that included to monitor for dehydration, extra fluids and monitor labs.
An Enteral Feeding Initial Assessment dated 2/5/10 completed by a Dietary Technician (DT) identified Resident #8 with the following dehydration risk factors: dysphagia, GT, P/Us, diuretics, and oxygen. The DT also documented that the resident was receiving Osmolite 1.2 1000 cc at 70 cc/hr and Liquid Protein Supplement (LPS) 30 cc twice daily via GT. The DT documented that the GT feeding and LPS supplement provided a total free water of 2070 milliliters (ml). The DT's estimated fluid requirements for Resident #8 were documented to be calculated at 25 cc/kilogram (kg) and were 1221 ml/day. The DT's assessment also documented that the resident was at risk for weight loss, malnutrition and dehydration. Additionally, the assessment documented in the plan section: recommend to adjust before feeding (ac)/after feeding (pc) and extra fluids via GT every shift.
The Minimum Data Set (MDS) Significant Change Assessment dated 2/10/10 documented that the resident was severely impaired in cognition and was totally dependent in all Activities of Daily Living (ADLs). The MDS documented that the resident had a swallowing problem and received nutrition via a GT. The MDS documented that the resident had received during the past 7 days an average fluid intake per day between 1501 to 2000 cubic centimeters (cc)/day. Additionally, the MDS documented that the resident had one Stage II and two Stage I P/Us.
The facility Laboratory (Lab) Report collected 2/5/10 and reported on 2/6/10 documented the following: Blood Urea Nitrogen (BUN) 31 mg/per deciliter (mg/dl) (reference range 6-24), Creatinine 0.36 mg/dl (reference range 0.70-1.50), and Sodium 143.0 millimole/per liter (mmol/L) (reference range 135-148). (BUN is a measure of the amount of nitrogen in the blood in the form of urea, and a measurement of renal function. The Creatinine blood test is used along with a BUN to assess kidney function. Sodium is an electrolyte. The Sodium level is used to measure hydration.)
The electronic physician's order dated 2/10/10 at 2:10 PM documented to discontinue the additional 250 cc of extra fluids via GT every shift. The physician's orders documented to provide 200 cc of extra fluids via GT every shift at 6:00 AM, 2:00 PM, and 10:00 PM.
The 2/10/10 order was electronically signed off by the Primary Physician (PMD) on 2/10/10 at 2:10 PM. There was no documented evidence on the electronic order form that these orders were reviewed by nurses on the three subsequent shifts.
The Electronic Medication and Treatment Administration Record (EMAR and ETAR) for February 2010 contained no documented evidence that the extra fluids ordered on 2/4/10 and 2/10/10 were transcribed and administered accordingly.
The Nurses Notes dated 2/5/10 through 2/15/10 were reviewed and contained no documented evidence that the extra fluids ordered via GT on 2/4/10 and 2/10/10 were administered as ordered.
The facility Lab Report collected on 2/15/10 and verified by repeat analysis on 2/15/10 documented the following: BUN 61, Creatinine 0.57 and Sodium 156.0.
A Nurses Note dated 2/15/10 at 4:19 PM documented that the nurse received "panic" Lab results of a BUN of 61, a Creatinine of 0.57, and a Sodium level at 156. The note also documented that the PMD was notified and ordered the resident to be transferred to the hospital for an electrolyte imbalance.
The Hospital History and Physical Medical Record dated 2/15/10 documented that the resident "was brought to the emergency room because the patient was being Lethargic and Tachypneic (rapid, shallow breathing)." The Record also documented the diagnoses on admission that include Severe Hypernatremia (increased concentration of Sodium in the blood ) and Acute Azotemia (presence of increased nitrogenous bodies especially urea in increased amounts in the blood).
The Hospital Laboratory Report dated 2/15/10 at 6:03 PM documented the following results: BUN 56 (reference range 8-20 mg/dl), Creatinine 0.7 (reference range 0.4-1.0 mg/dl), and Sodium 155.0 (reference range 136-144 mmol/L).
The Hospital and Community Readmission Patient Review Instrument (PRI) dated as completed on 2/25/10 documented Hypernatremia/Azotemia as primary diagnoses. The PRI also documented that during the past week that the resident had a diagnosis of Dehydration.
An interview was conducted with the unit 7:00 AM-3:00 PM Shift Licensed Practical Nurse (LPN) on 3/10/10 at 11:00 AM. The LPN stated that all GT extra fluids should have been recorded on the EMAR.
An interview was conducted with the RN Charge Nurse (where the resident currently resides) on 3/10/10 at 11:30 AM. The RN stated that all GT extra fluids should be recorded in the EMAR.
An interview with the RN Charge Nurse (the nurse on the unit where the resident was readmitted on 2/4/10 and who picked up the orders) was conducted on 3/10/10 at 1:30 PM. The RN stated that all GT extra fluids should be recorded in the EMAR. The RN also stated that the GT extra fluids ordered should have been picked up and reviewed by the nurses on the following two shifts. The RN could not explain why the additional fluids orders had not been transcribed and administered. The RN also could not verify if the extra fluids were actually administered since the extra fluids orders were not transcribed to the EMAR.
An interview with the Primary Physician (PMD) was conducted on 3/10/10 at 1:00 PM. The PMD stated that the resident should have received the extra fluids as ordered on 2/4/10 and 2/10/10. The PMD further stated that he relied on the Dietitian's recommendations for extra fluids and that the resident was on Lasix 40 mg daily. The PMD stated that the Lasix placed the resident at greater risk of Dehydration. The PMD stated that a BUN of 61 and a Sodium of 156 reflected severe dehydration. The PMD stated that is why he had ordered a Basic Metabolic Profile (BMP - blood work to evaluate electrolytes, renal function and glucose) twice weekly to play it safe upon the resident's readmission on 2/25/10. The PMD further stated that if the resident had received the fluid flushes every shift as ordered that she would not have had a Sodium level of 156 mg.
An interview was conducted on 3/10/10 at 2:00 PM with the DT that had completed Enteral Feeding Assessment on 2/5/10. The DT stated that she documented that the GT feeding met the residents fluid needs by calculating the fluids provided from the GT feeding itself, the fluid flushes provided before and after the feeding and the additional fluid flushes provided at each shift. The DT also stated that she does not review the EMARs to check that the Physician's Orders for GT feeding accuracy. The DT further stated that the resident should have received the water flushes every shift as prescribed by the physician.

An interview was conducted on 3/10/10 at 2:30 PM with the Food Service Director (FSD) that is responsible for the Dietitians/DT. The FSD stated that the fluid flushes should have been on the EMAR. The FSD also stated that she does not expect her dietary staff to confirm that the EMAR matches the physicians GT orders. The FSD further stated that when her staff calculate the fluids received via a GT order that they do not include the fluids provided during medication passes as part of the total fluids received. Additionally, the FSD stated that the fluids from medications are not included because the volume of fluid is not a fixed amount because medications are changed very frequently.

An interview was conducted with the Director of Nursing Services (DNS) on 3/10/10 at 4:00 PM. The DNS stated that she reviewed the EMAR today and identified that the fluid flushes for Resident #8 had not been transcribed to the EMAR. The DNS stated that three licensed staff members are required to sign off on any physician order to confirm that it had been appropriately transcribed to the EMAR. The DNS stated that the fluid flushes should have been on the EMAR.

415.12(j)
0

Based on observation, record reviews and staff interviews during the recertification survey, the facility did not ensure that resident's Advanced Directives (AD) were maintained as per the facility's written policies and procedures . Specifically, one (Resident #10) of thirty resident's reviewed for ADs had a Physician's Order for Do Not Resuscitate (DNR) without a facility consent for the DNR. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #10)

The finding is:

Resident #10 was readmitted 12/9/09 and has diagnoses that include Hypertension and Sinus Bradycardia.

The Minimum Data Set (MDS) Assessment dated 12/12/09 documented the resident's cognition as moderately impaired.

The resident was observed on 3/8/10 at 10:00 AM and on 3/10/10 at 10:00 AM sleeping in bed wearing an identification bracelet containing a yellow dot.

The Social Services Progress Note dated 12/2/09 documented that the resident was transferred to the hospital and admitted with Sepsis (generalized infection). The subsequent Social Services note dated 12/9/09 documented that the resident had returned to the facility and that the Health Care Proxy (HCP) remained implemented on the chart.

There was a hospital DNR consent and a hospital Physician's Order for a DNR dated 12/1/09 that documented a signature of the HCP (resident's niece) and the signature of the Physician responsible for the resident while in the hospital.

There were subsequent hospital DNR order and consent forms signed and dated 2/21/10 and renewed on 2/28/10.

The facility Electronic Physician's Orders dated 3/5/10 documented an order for a DNR. The was no documented evidence in the Electronic Medical Record (EMR) that the HCP had executed a DNR consent when the resident returned to the facility.

An interview with the Attending Physician was conducted on 3/10/10 at 8:30 AM. The Physician stated that the hospital-executed DNR consent was only valid for 72 hours after readmission to the facility and that a facility-executed DNR consent should have been in place.

An interview with the Registered Nurse (RN) Charge Nurse was conducted on 3/10/10 at 9:00 AM. The RN stated that she could not locate a facility-executed DNR consent. The RN stated that a yellow dot on the identification bracelet indicates that the resident had a DNR order.

The undated Policy titled Do Not Resuscitate was reviewed. The Policy did not document how to proceed if a resident is admitted from the hospital with a DNR order.

415.3 (e)(2)(iii)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that necessary services were provided to attain the resident's highest practicable, physical well-being. This was evident for 1 of 1 Resident (#27) reviewed for Dialysis Services in a total of 30 sampled residents. Specifically, the Registered Dietitian (RD) from the Dialysis Center documented in the resident's facility Communication Book on three occasions (4/19/09, 4/30/09, 6/13/09) a request to be contacted for a recommendation for a protein supplement for the resident related to the resident's low Albumin (protein in the blood) blood levels. There was no documented evidence that the facility staff noted or responded to the communication until 8/5/09, when a protein supplement was ordered for Resident #27. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #27 has diagnoses which include End Stage Renal Disease and Hypertension.

The Physician's Monthly Orders dated 4/15/09 through 8/5/09 documented that the resident attended dialysis three times a week.

Upon review of the resident's Dialysis/Facility Communication Book the following was noted:

1) The RD from the Dialysis Center documented on 4/19/09 a recommendation for a modular (high protein) protein supplement. The RD documented that the resident's Albumin level was a borderline level at 3.8 and the level for Resident #27 should be kept at 4.0. There was no documented evidence of facility review or follow up to this request in the medical record.

2) A communication dated 4/30/09 by the Dialysis Center RD documented a request for an order for a modular protein supplement twice daily. The Albumin level was documented at 3.9. The RD documented that it should be 4.0 for this resident. There was no documented evidence that this recommendation was addressed.

3) On 6/13/09 the Dialysis Center RD documented ". . .I would like to recommend a modular protein supplement BID (twice daily)." The RD further documented that the resident's Albumin level was not progressing to the appropriate level. There was no documented evidence in the medical record that this recommendation was addressed.

The Dialysis Center RD documented in the Dialysis Communication Book on 7/30/09 a communication note addressing the resident's physician and stated that the resident had a declining Albumin trend (5/14/09 was 3.9, 6/11/09 was 3.7, 7/16/09 was 3.6). The RD recommended the supplement of Liquid Protein Supplement (LPS) 30 cubic-centimeters (cc) twice daily.

On 8/5/09 the Physician's Monthly Order included an order for the supplement LPS 30 cc twice daily.

The Dialysis Communication Book dated 8/12/09 notified the Dialysis Center RD that the resident was placed on the recommended supplement of LPS.

The Agreement between the Dialysis Unit and the facility signed 7/30/01 documented that the coordination of care includes the communication between the facility and the Dialysis Unit.

The facility RD was interviewed on 3/11/10 at 10:40 AM. The RD stated that the Registered Nurse (RN) Manager or the facility RD were responsible to look at the Communication Book. The RD further stated that the resident's Dietitian should have established contact with the Dialysis Unit RD by phone as was requested in the Communication Book. The RD also stated that the resident's protein needs should have been addressed with the initial request.

415.12

Based on record review and staff interviews during the recertification survey, the facility did not ensure that one of 30 sampled residents was free of any significant medication error. Specifically, Resident #8 had a Nitro-Dur patch (Nitro-Dur patch is a continuous controlled release of nitroglycerin through intact skin used to control and prevent chest pain) order that was not implemented as prescribed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #8 has diagnoses including Congestive Heart Failure and Hypertension.

The MDS Significant Change Assessment dated 2/10/10 documented that the resident was severely impaired in cognition and was totally dependent in all Activities of Daily Living (ADLs).

The electronic Physician's Order dated 2/25/10 documented Nitro-Dur 0.4 milligrams/hour (mg/hr) Transdermal 24 hr patch and Protocol: Apply patch at 9:00 PM and remove at 9:00 AM.

The RN Charge Nurse was interviewed on 3/8/10 at 12:40 PM. The RN stated that the Resident's Nitro-Dur patch is applied at 9:00 AM and removed at 9:00 PM. The RN's statement was in contradiction to the physician's order for the patch.

On 3/8/10 at 12:45 PM, the resident was observed resting in a reclined gerichair by the nursing station. It was noted, in the presence of the RN Charge Nurse, that the Nitro-Dur patch was still on the Resident's right upper chest wall.

The RN Charge Nurse was immediately interviewed on 3/8/10 at 12:45 PM after observation. The RN stated that she was not aware that the order was to remove the Nitro-Dur patch at 9:00 AM.

The March 2010 Electronic Medication Administration Record (EMAR) was reviewed. The MAR documented Nitro-Dur 0.4 mg/hr Transderm 24 hr patch and Protocol: Apply patch at 9:00 PM and remove at 9:00 AM. The EMAR also documented that the nurse signed that the patch was removed on 3/8/10 at 9:00 AM.

The agency Licensed Practical Nurse (LPN) #1, that worked on 3/8/10 from 8:00 AM-12:00 PM and signed the EMAR that the Nitro-Dur patch was removed on 3/8/10 at 9:00 AM, was not available for interview.

The 7:00 AM-3:00 PM shift LPN #2 that worked regularly on the resident's unit was interviewed on 3/8/10 at 12:50 PM. The LPN stated that the resident's Nitro-Dur patch is applied at 9:00 AM and removed at 9:00 PM. (This reflected a contradiction to the Physician's Order for the patch.) The LPN further stated that the agency LPN #1 had already left the facility.

The Nurses Note dated 3/8/10 at 1:55 PM documented "Resident on Nitro patch AM. Nurse suppose to remove at 9:00 AM instead remove patch, new patch at 10:00 AM applied on resident. As soon as noted, patch was removed. Vital sign taken. MD made aware. MD ordered monitor BP every 4 hours times 24 hours. No distress noted ...".

The Medical Director (MD) was interviewed on 3/9/10 at 11:15 AM. The MD stated that Nitro-Dur patch was ordered as written and should have been followed as written.

The pharmacy provider was interviewed on 3/10/10 at 11:40 AM. The Pharmacist stated that the resident should have a "nitrate-free" period to prevent the decrease in the effectiveness of the Nitro-Dur patch. The Pharmacist further stated that if the Nitro-Dur patch was left longer than 12 hours, the resident could experience adverse side effects such as low blood pressure and headache.

415.12(m)(2)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that one of thirty sampled residents physician's orders were followed. Specifically, Resident #7 had an order for a nutritional supplement that was not implemented timely, as prescribed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #7 was readmitted to the facility on 2/25/10 and has diagnoses that include Diabetes Mellitus and Alzheimer's.

The Minimum Data Set (MDS) Assessment dated 3/4/10 documented the resident's cognition as moderately impaired. The MDS also documented that the resident had two Stage I Decubitus Ulcer's (DU) and one Stage II DU.

The Physician's Order Form dated 2/25/10 at 4:32 PM documented an order for Glucerna Shake (liquid nutritional supplement) 8 ounces by mouth daily at 10:00 AM and 2:00 PM.

The Electronic Medication Administration Record (EMAR) dated February 2010 was reviewed. There was no documented evidence on the EMAR that the Glucerna had been transcribed.

The EMAR dated March 2010 was reviewed. The EMAR documented that the Glucerna was initiated on 3/2/10 at 2:00 PM.

An interview was conducted on 3/10/10 at 10:00 AM with the Director of Nursing Services (DNS). The DNS stated that the resident should have received the supplement by 2/26/10. The DNS was unable to explain why the supplement was not transcribed.

415.11(c)(3)(i)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that services were provided in accordance with standards of professional nursing practice to two of two resident's receiving a Fentanyl patch (a narcotic to relieve pain) of thirty sampled resident's. Specifically, Residents #10 and #11 had a physician's order for a Fentanyl patch that required two Licensed Nurses signatures when the patch was removed and discarded. The residents' Medication Administration Record (MAR) did not contain documented evidence that this requirement was followed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #10 has diagnoses that include Hypertension and Sinus Bradycardia.

The Minimum Data Set (MDS) Assessment dated 12/12/09 documented the resident as experiencing moderate pain on a daily basis.

The MAR for the month of September 2009 was reviewed. There were seven omissions of two licensed nurse's signatures documenting the removal of the Fentanyl patch.

The MAR for the month of October 2009 was reviewed. There were four omissions of two licensed nurse's signatures documenting the removal of the Fentanyl patch.

The MAR for the month of November 2009 was reviewed. There were three omissions of two licensed nurse's signatures documenting the removal of the Fentanyl patch.

2) Resident #11 has diagnoses that include Stage IV Pressure Ulcer (D/U) and Generalized Pain.

The MDS Quarterly Assessment dated 12/8/09 documented that the resident was severely impaired in cognition and one Stage IV D/U.

The MAR for the month of September 2009 was reviewed. There were eight omissions of two licensed nurse's signatures documenting the removal of the Fentanyl patch.

The MAR for the month of October 2009 was reviewed. There were no documented evidence of two licensed nurse's signatures documenting the removal of the Fentanyl patch for the month.

An interview was conducted on 3/11/10 at 10:00 AM with the Registered Nurse (RN) Charge Nurse. The RN stated that there should be two licensed nurse's signatures documented on the MAR in attestation to the removal and discarding of the residents' Fentanyl patch.

415.11(c)(3)(i)

Based on observation and staff interviews during the recertification survey, the facility did not ensure that a Licensed Practical Nurse (LPN) followed proper handwashing during one of three treatment observations made in a total of thirty sampled residents (Resident #4). Specifically, one LPN was observed rendering a treatment to a Stage II Sacral Decubitus Ulcer (DU) to Resident #4 without washing her hands. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is a repeat deficiency.

The finding is:

Resident #4 has diagnoses that include Dementia and a Decubitus Ulcer.

The Minimum Data Set (MDS) Assessment dated 3/1/10 documented that the resident had modified independence in cognition. The MDS also documented that the resident had two Stage I and one Stage III DUs.

Resident #4 was observed on 3/10/10 at 10:30 AM during a Stage II Sacral DU treatment. The LPN and Registered Nurse (RN) Wound Nurse were present. The LPN was observed washing her hands prior to preparing her treatment area. Once the area was prepared the LPN removed the old dressing and her gloves. The LPN re-gloved and cleansed the sacral area with 3 normal saline soaked gauze pads. The LPN then removed her gloves and re-gloved to pat the wound bed dry. Again, the LPN removed her gloves and re-gloved to apply Silvadene creamed gauze and protective dressing. After the initial hand washing prior to preparing the treatment area that at no time during the treatment up to the completion of the treatment was the LPN observed to have washed her hands.

The LPN was interviewed immediately after the treatment was completed on 3/10/10 at 10:50 AM. Initially, the LPN stated that she had washed her hands during the completion of the treatment. The LPN then acknowledged that she had not washed her hands during the treatment, but stated that she did not need to.

The RN Wound Nurse was interviewed on 3/10/10 at 10:55 AM. The RN stated that the LPN had not washed her hands during the treatment. The RN further stated that the LPN should have washed her hands after setting up her area, removing the old dressing, after cleansing the wound and after placing the dressing.

The undated Policy titled Clean Dressing was reviewed. The Policy documented that after the soiled dressing was removed the gloves are removed and hands are washed. The policy further documented that after the cleanse of the wound and after the dressing has been secured gloves are to be removed and hands are to be washed.

415.19(b)(4)

Based on observation and staff interview, two gates that separate the back patio from the public way swing against the direction of egress.

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

The finding is:

On 3/8/10 between 9:00am- 2:00pm during the recertification survey, exit discharge from the back patio terminates at two separate gates that swing against the direction of egress.

In an interview on 3/8/10 at approximately 11:10am, the Director of Building Services stated that she would have the hinges reversed to swing with the direction of egress immediately.

711.2(a)(1)