Table of Contents
Woodland Pond at New Paltz
Deficiency Details, Certification Survey, March 22, 2011
PFI: 9136
Regional Office: MARO--New Rochelle Area Office
F278 483.20(g) - (j): ACCURACY OF ASSESSMENTS/COORDINATED WITH PROFESSIONALS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: April 30, 2011
The assessment must accurately reflect the resident's status. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. A registered nurse must sign and certify that the assessment is completed. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Under Medicare and Medicaid, an individual who willfully and knowingly certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or an individual who willfully and knowingly causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment. Clinical disagreement does not constitute a material and false statement.
Citation date: March 22, 2011
Based on record review and interview the facility did not ensure that each portion of an MDS 3 (an an assessment ) was accurate. Specifically a resident's height was inaccurately documented in an initial MDS 3. This was evident for 1 of 30 Admission Sample reviews) (# 6)
This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Resident # 6's record was reviewed during Admission Sample Review.
A review of the initial MDS 3 (Minimum Data Set- an assessment) of 2/2/11 revealed that the resident's height had been documented as 48"(inches).
A review of the resident's weight tracking report revealed that the resident's height was 148". A review of the Nursing admission/readmission tracking tool revealed that the residents height was 5'1" ( 5 feet. 1 inch).
Interview with facility dietitian on 3/16/11 at 5:00PM revealed that upon resident admission " a nurse or an aide enters the height and weight of the resident into the computer". According to this interview , when documenting the MDS 3 the dietitian reviewed the height and thought that the resident could not possibly be 148" ; and by error entered 48" for resident height.
A review of Federal Regulation 483.20 (g) Accuracy of Assessment revealed that that " The initial comprehensive assessment provides baseline data for ongoing assessment of resident progress".
415.11(b)
F272 483.20(b)(1): COMPREHENSIVE ASSESSMENTS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: April 30, 2011
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. A facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument (RAI) specified by the State. The assessment must include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication; Vision; Mood and behavior patterns; Psychosocial well-being; Physical functioning and structural problems; Continence; Disease diagnosis and health conditions; Dental and nutritional status; Skin conditions; Activity pursuit; Medications; Special treatments and procedures; Discharge potential; Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS); and Documentation of participation in assessment.
Citation date: March 22, 2011
Based on record review and staff interviews the facility did not ensure that an initial and a periodic comprehensive and accurate nutritional assessment was done for each resident . This was evident for 1 of 29 Stage II sampled residents. (Resident # 20)
This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings are :
Resident # 20 was an 86 year old female admitted on 2/3/11 with diagnoses including Right patella fracture (right knee),Gluten Intolerance, Diabetes Mellitus and Iron Deficient Anemia.
Record review on 3/17/11 revealed that the 2/3/11 Admission -Readmission - Data Collection Tool had documented the resident's admission weight was 112.4 lbs. (pounds) and no height for the resident was entered.
In a review of the Minimum Data Set dated 2/10/11 documented resident's admission weight as 122 lbs and her height as 62".
A review of the Initial Nutrition Assessment revealed that the resident's weight had been documented as 112.4 lbs with no height .
In an interview with the Director of Nursing on 3/22/11 at 11:00AM she stated the weight documented on the Admission -Readmission -Data Collection Tool was the accurate weight and the resident was weighed at the time of the admission.
In and interview with the Dietician on 3/22/11 at 1:15 PM she stated she "guesstimated" the resident's height to calculate the resident's ideal body weight (IBW) . Nutritional needs are based on the IBW.
Review of the Resident Weight Tracking System Report revealed that the first submitted weight was on 2/9/11 as 102 lbs. and the most recent weight as of 3/12/11 as 104.20 lbs.
In a subsequent interview with the Dietician on 3/22/11 at 2 PM she had no explanation as to why there were no re -weights recorded since the admission weight on 2/3/11 was documented as 122 lbs and the next documented weight was 102 pounds on 2/9/11( a 20 lb weight loss in 6 days).
Review of the nutritional care plan evaluated on 2/16 /11 documented by the dietician stated continue current interventions and again on 3/1/11 .
.The initial care plan of 2/3/11 was reviewed by the Dietitian on 2/16/11 and 3/1/11 respectfully. There were no new interventions or revisions of the careplan to address the documented weight loss.
415.11(a)(2)
t
F279 483.20(d), 483.20(k)(1): DEVELOP COMPREHENSIVE CARE PLANS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: April 30, 2011
A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ¾483.25; and any services that would otherwise be required under ¾483.25 but are not provided due to the resident's exercise of rights under ¾483.10, including the right to refuse treatment under ¾483.10(b)(4).
Citation date: March 22, 2011
Based on interview, and record review the facility did not ensure that a care plan with interventions was developed for each resident to provide the applicable care and services. Specifically , a care plan, addressing the care of a suprapubic catheter , was not developed for a resident with a suprapubic catheter and accompanying Chronic Cystitis. This was evident for 1 of 29 Stage 2 sampled residents. (#12)
This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings are:
Resident # 12 was admitted on 2/2/11 with diagnoses including Benign Hypertension and Unspecified Cerebral Artery Occlusion
.
A review of the 2/1/11 pre admission assessment documented that the resident had a permanent supra pubic catheter for BPH (Benign Prostate Hypertrophy), and has chronic cystitis (Bladder infection). A review of inter agency transfer form of 2/2/11 revealed that this resident has chronic cystitis. A review of hospital records for 1/18/11 revealed that this resident had the suprapubic catheter on admission to the hospital.
A review of a Urological Consultation of 3/8/11 revealed that the resident had urinary retention and bladder spasms with leakage.
A review of the initial MDS 3 (Minimum Data Set - an assessment) of 2/14/11 revealed that this resident had an indwelling catheter (includes suprapubic catheter).
Chronic Cystitis ( Urinary Tract Infection/UTI ), urinary retention and bladder spasms with leakage are resident needs and there is no care plan available to address these needs,
Interview was done on 3/21/11 at !:52PM with Director of Nursing (DNS) to determine if a care plan had been done and had not been entered into the computer. The DNS was unable, at that time, to answer the inquiry . On 3/21/11 at 2:45 PM the DNS stated that she had just put together an episodic care plan to address management of chronic urinary retention with accompanying cystitis.
415.11(c)(1)
F280 483.20(d)(3), 483.10(k)(2): DEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: April 30, 2011
The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.
Citation date: March 22, 2011
Based on observation, record review and staff interview, the facility did not ensure a residents' plan of care were periodically reviewed and revised. Specifically (1) a resident's nutritional care plan was not revised to discontinue the use of plastic utensils at mealtimes ( Resident #16), and (2) a resident's care plan was not revised to address weight loss Resident #20). This was evident for 2 of 29 residents reviewed in the Stage 2 sample on 1 of 1 units.
This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings are:
1. Resident #16 has a diagnosis of Dementia. The resident was observed eating with plastic utensils on 3/21/11 at 12:20PM, across from the nurse's station on the unit.
A review of the resident's Comprehensive Care Plan for Nutrition dated 9/7/10 (6 months ago) indicated that the resident was to receive plastic utensils with all his meals. However, there was no explanation in the care plan as to why the resident needed to eat with the plastic utensils. Additionally, there was no indication on the written care plan that the Interdisciplinary Team Members ever reviewed the care plan to discontinue the plastic silverware.
In an interview with the facility Social Worker on 3/22/11 at 8:00AM, she stated that the resident in the past had been taking his silver ware back to his room, and that was why the resident was given the plastic utensils to eat with at meal time. When asked if any other interventions were tried, she said that she was not aware of any.
2 )Resident # 20 was an 86 year old female admitted on 2/3/11 with diagnoses including Right patella fracture (right knee),Gluten Intolerance, Diabetes Mellitus and Iron Deficient Anemia.
Record review on 3/17/11 revealed that the 2/3/11 Admission -Readmission - Data Collection Tool had documented the resident's admission weight was 112.4 lbs and no height for the resident was entered.
A review of the Minimum Data Set dated 2/10/11 documented the resident's admission weight as 122 pounds (lbs.) and her height as 62 inches.
Review of the Initial Nutrition Assessment had the resident's weight as 112.4 lbs with no height .
In an interview with the Director of Nursing on 3/22/11 at 11:00am she stated the weight documented on the Admission -Readmission -Data Collection Tool was the accurate weight and the resident was weighed at the time of the admission.
In an interview with the Dietician on 3/22/11 at 1:15pm she stated she "guesstimated" the resident's height to calculate the resident's ideal body weight (IBW) and her nutritional needs.
Review of the Resident Weight Tracking System Report revealed that the first submitted weight was on 2/9/11 as 102 lbs( pounds). This was 10lb weight loss per the Admission -Readmission -Data Collection Tool and a 20lb weight loss per the initial Minimum Data Set(MDS).
Review of the Interdisciplinary Notes by the Dietician dated 2/16/11 documented the resident's current weight as 122 lbs and goal weight was 115 -125 lbs.
Review of the Resident's Weight Tracking System Report for 2/9/11 has resident's weight documented as 102 lbs. and has resident's weight on 2/17/11 as 101.2 lbs.
There were no revision of the care plan to address the documented weight loss.
415.11(c)(2)(i-iii)
F241 483.15(a): DIGNITY
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: April 30, 2011
The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.
Citation date: March 22, 2011
Based on observation, record review and staff interview, the facility did not promote care in a manner that maintains each resident's dignity. Specifically, (1) a resident was observed eating with plastic utensils on the unit ( Resident # 16), (2) a sign on a communication board, in the resident's room, referred to the resident as " Hi Trouble" (Resident #12). This was evident for 2 of 29 residents reviewed in the Stage 2 sample on 1 of 1 units.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The findings are:
1. Resident #16 has a Diagnosis of Dementia. The resident was observed eating with plastic utensils on 3/21/11 at 12:20PM, across from the nurse's station on the unit.
A review of the resident's care plan for nutrition dated 9/7/10 (6 months ago) indicated that the resident was to receive plastic utensils with all his meals. However, there was no explanation on the care plan why the resident needed to eat with the plastic utensils.
In an interview with the facility Social Worker on 3/22/11 at 8:00AM, she stated that the resident had been taking his silver ware back to his room, and that was why the resident was given the plastic utensils to eat with at meal time. When asked if any other interventions were tried, she said that she was not aware of any.
2. Observation made during med pass administration to Resident # 12
on 3/18/11 at 9:10AM revealed a salutation written on the white communication board in the resident's room ( in large black print) " HI TROUBLE ". and the name of assigned Certified Nurse Aide (CNA).
During resident interview, at that time, regarding the salutation on the communication board the Resident indicated that he must be trouble.
A review of the assignment sheet dated 3/9/11 revealed that the named CNA was assigned to "Run 1"- where the resident resides on 3/9/11. Further review of CNA assignment sheets revealed that the named CNA was on duty on 3/21/11.
Interview with the CNA (whose name was on the resident's communication board 3/9/11) on 3/21/11 at 2:15PM revealed that she saw the " HI TROUBLE " salutation written on the communication board in the resident's room on 3/9/11 and had erased it . The C.N.A. indicated that she had told the aides on all shifts that to put something like this on a communication board in the resident's room was inappropriate and should never be done. This interview revealed that someone must have re written the salutation on the communication board after she (CNA) erased it on 3/9/11.
This communication board was clearly visible to anyone entering the resident's room.
415.5(a)
F334 483.25(n): INFLUENZA AND PNEUMOCOCCAL IMMUNIZATION
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: April 30, 2011
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: March 22, 2011
Based on record review and interview the facility did not develop a policy and proceedure that ensures that before offering the influenza and pneumoccocal immunizations, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization. Specifically, two residents had no documentation regarding education of the benefits and risks of the influenza and pneumoccocal immunizations. This was evident for 2 of 29 sampled residents.(Residents #12 and # 68 on 1 of 1 facility units).
This resulted in minimal harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
Medical record reviews of the influenza and pneumococcal documentation revealed that Residents #12 and #68 respectively, did not have evidence of education prior to the administration of the influenza and pneumococcal vaccines.
Interview with the Director of Nursing (DON) on 3/18/11 at 2:30PM revealed that she was unaware of the need for documentation of education prior to the administration of the influenza and pneumococcal vaccines.
415.13(b)(1)
F431 483.60(b), (d), (e): PROPER LABELING OF DRUGS AND BIOLOGICALS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: April 30, 2011
The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Citation date: March 22, 2011
Based on observation and interview regarding the facility's Medication Storage Room, the facility did not ensure that: 1. the medications in the Emergency Box containing Intravenous (IV) Supplies were up to date. 2. a Sharps Recepticle was available in the Medication Storage Room. 3. a discharged resident's (personal- brought in from home) controlled (Narcotics) were returned to them or counted shift to shift (to ensure no diversion of these drugs) or sent to the Pharmacy. This was evident in the facility's Medication Storage Room.(1of1)
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
Inspection of the facility's Medication Storage Room on 3/16/11 at 10:30AM revealed the following:
1. The Intravenous (IV) Therapy Emergency Box contained 2 packaged syringes containing Heparin (used to flush the IV site) that were out dated since 2/1/11.
2. A Sharps Container (to dispose of used syringes and sharp materials) was not available in the Medication Storage Room.
3. Several packages of Narcotic Medications belonging to a discharged resident were noted in the Narcotic Cabinet. Records of accounting for these medications shift to shift were not available.
Interveiw with the Medication Licensed Practical Nurse(LPN) at that time, revealed that she had no explanation regarding these three issues. The LPN added that the discharged resident's Narcotic medications were not counted shift to shift.
In an interview with the Director of Nursing (DON) on 3/16/11 at 11:45AM revealed that she had no explanation regarding these three issues in the Medication Storage Room.
415.18(d)
00
F156 483.10(b)(5) - (10), 483.10(b)(1): INFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.
Scope: Pattern
Severity: Potential for no more than Minimal Harm
Corrected Date: April 30, 2011
The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under ¾1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing. The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section. The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. The facility must furnish a written description of legal rights which includes: A description of the manner of protecting personal funds, under paragraph (c) of this section; A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels. A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.
Citation date: March 22, 2011
Based on record review and staff interview , the facility did not provide Medicare residents the appropriate liability and appeal notices. Specifically, (1) the liability and appeal notice form did not document when the resident's Medicare coverage was expected to end ( Resident #17) and (2) the liability and appeal notice form did not indicate the date when the resident with Medicare Coverage received the written notice ( Resident #34). In addition, the liability and appeal notice did not indicate the name of the Quality Improvement Organization (independent reviewer) or how to reach them by telephone ( Resident #17, 34). This was evident for 2 of 3 residents reviewed for liability and appeal notices on 1 of 1 units.
This resulted in no actual harm with the potential for minimal harm.
Findings are:
1. Resident #17 was admitted with Medicare coverage on 9/1/10 for skilled care (physical and occupational services) provided by the facility. The facility gave the resident/family member a written liability and appeal notice on 9/29/10 that the Medicare coverage for the skilled care would be ending. However there was no date on the liability and appeal notice when the resident's Medicare services was anticipated to end. Resident /family members must get a minimum of 2 days notice.
2. Resident # 34 was admitted on 1/21/11 with Medicare coverage for skilled care provided in the facility. The resident was notified in writing, by the facility that the anticipated date when Medicare services would be ending. However, there was no date on the facility's liability and appeal form when the form was sent to the resident/family member.
In addition, both the liability and appeal notice forms for non coverage of Medicare services did not note the Quality Improvement Organization and the telephone number where they can be reached (Resident # 17, 34).
In an interview with the facility's Comptroller on 3/22/11 at 9:00AM, she was unable to give an explanation for the missing information.
415.3[e][2][iii]
F287 483.20(f): RESIDENT ASSESSMENT AUTOMATED DATA PROCESSING
Scope: Pattern
Severity: Potential for no more than Minimal Harm
Corrected Date: April 30, 2011
(1) Encoding Data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. (2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. (3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i) Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on a resident that does not have an admission assessment. (4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Citation date: March 22, 2011
Based on record reviews and interviews the facility did not ensure that MDS 3's were submitted for each resident in the certified Medicare/Medicaid unit ;and/or that these submissions were within 14 days after completion of a resident's assessment. This was evident for 2 residents not included in the resident pool (residents admitted within 180 days prior to survey), but included in the alphabetical list of residents in the facility. This was evident for 4 of 29 Stage 2 sampled residents (# 71, #81, # 78, # 79)
This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.
Findings are:
During observation of medication administration pass on 3/17/11 at 10:15 AM to resident
# 71 it was noted that this resident was not in the Resident Pool.
On 3/17/11 at 12:55PM the Director of Nursing (DNS) was asked for the MDS (an assessment) transmittal dates of this resident.
Interview with the DNS on 3/17/11 at 1:06PM revealed that resident # 71's payor source is BlueCross/Blue Shield and since the resident is considered private pay CMS (Center Medicare/Medicaid Services) will not accept the MDS as "it is not their business". This interview also revealed that another resident (#81)has No Fault as a payor source and is considered private pay and does not require MDS submission. Interview with the MDS nurse on 3/17/11 t 2:10PM revealed that another resident (# 78 ) was
admitted as a private resident and required no MDS submission. This interview also revealed that Resident # 71 and Resident # 81 are considered private pay and the MDS does not have to be submitted; also that Resident # 79's 5 day MDS was submitted 10/15/10 more than 32 days after completion.
A review of MDS Final Validation Reports for Residents # 78 and #79 revealed that the MDS for Resident # 78 was "submitted late, more than 31 days after the record completion date" and that Resident # 79's MDS was transmitted on 10/15/10,also more than 32 days after record completion.
Interview with staff member in charge of Health Information Management on 3/21/11 at 1:30PM revealed that she too had been under the impression that the MDS of residents considered to be " Private Pay" did not have to be submitted to CMS.
A review of the MDS 3.0 File Submission list revealed that the MDS for Resident # 71 was submitted on 3/21/11 (after surveyor intervention). The facility provided no evidence of MDS submission for resident # 81.
A review of Appendix R of the State Operation Manual, Chapter 5 ( Submission and Correction of the MDS Assessment) under NY(New York Requirement) revealed "Federal authority requiring submission of MDS assessment data applies to all residents residing in Medicare and /or Medicaid certified long-term care facilities". The skilled nursing unit of Woodland Ponds is a certified Medicare/Medicaid unit.
415.11 (a)(5)nenene