Niagara Lutheran Home & Rehabilitation Center Inc

Deficiency Details, Certification Survey, November 12, 2010

PFI: 0244
Regional Office: WRO--Buffalo Area Office

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F333 483.25(m)(2): RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 31, 2010

The facility must ensure that residents are free of any significant medication errors.

Citation date: November 12, 2010

Based on record review, staff and resident interview, the facility did not ensure that residents are free of any significant medication errors. One (Resident #10) of 26 residents reviewed for medication administration had an issue involving the administration of Heparin (blood thinner) after a physician order to discontinue the medication. In addition, the antipsychotic medication Clozapine was not administered as ordered. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding are:

1. Resident #10 has diagnoses including schizophrenia and a closed reduction of a left total hip replacement dislocation. Review of the Minimum Data Set (MDS) dated 11/4/10 revealed the resident is independent making decisions regarding tasks of daily life and has intact short term and long term memory, understands and is understood.

Review of a Hospital Summary Discharge Summary Report and facility admission orders dated 10/22/10 included an order for Clozapine 200 milligrams (mg) each morning and 250 mg each night (hs) for schizo-effective disorder related to her diagnosis of schizophrenia.

Review of the Consultant Pharmacist Record dated 10/29/10 revealed a notation to "(check) CBC q week (each week)- Clozapine".

Review of the Medication Administration Record (MAR) revealed "circled" (nurses) initials [indicating that a dose was not given] for the resident's 250 mg night time dose of Clozapine on 11/3/10 and 11/4/10, and for her 200 mg morning dose on 11/4/10. Review of the backside of the MAR entitled Nurse's Medication Notes revealed a notation dated 11/4/10 that "Clozapine not given - Waiting for blood work".

Review of the Physician Telephone Orders revealed an order dated 11/4/10 that includes "Clozaril (Clozapine) Obtain stat (immediately) CBC (complete blood count) x 1 NOW then q week (every week) use of Clozaril".

During an interview with the resident on 11/9/10 at 11:10 AM, the resident stated that (last week) she was "really upset" that she did not receive all of her medication (Clozapine) for two days and that she "had crazy dreams those nights".

During an interview with the Registered Nurse (RN) Coordinator on 11/10/10 at 9:30 AM, the RN stated that the pharmacy sent over an initial supply, but didn't inform us (the facility) that they would need the CBC blood work to provide additional amounts of the medication. The RN further explained the pharmacy would not deliver the Clozapine, even after they were informed the resident needed it.

During an interview on 11/12/10 at 10:05 AM with the Licensed Practical Nurse (LPN) who wrote this notation "Clozapine not given-Waiting for blood work" stated we "ran out of the medication, and didn't have any to provide to the resident".

During an interview with the Consultant Pharmacist conducted on 11/12/10 at 10:30 AM, the Pharmacist Consultant stated that these were not recommendations to nursing, but a reminder for her to check the weekly blood work. When interviewed on 11/12/10 at 10:30 AM, the Consultant Pharmacist explained that she was aware the dispensing pharmacy would not provide additional doses of Clozapine to the resident without weekly blood work. The Consultant Pharmacist explained that she was unaware the facility did not know this, and was not aware the dispensing pharmacy did not provide this as a recommendation to the facility. The Pharmacist finally added that she did not know the facility did not have enough medication to cover the resident before the additional lab work was completed.

b). Review of a Hospital Summary Discharge Summary Report and facility admission orders dated 10/22/10 included an order for Heparin (blood thinner) 5,000 units sq (subcutaneous - under the skin) every 8 hours for deep vein thrombosis (blood clot in the vein) prophylaxis (prevention).

Review of Physician's Orders dated 11/6/10 revealed the order to "D/C Heparin Pt. ambulating and request Heparin D/C'd".

Review of the Medication Administration Record (MAR) dated 11/1/10 to 11/10/10 revealed the resident received Heparin q8h 11/6/10 through 5:30 AM on 11/10/10. This was brought to the attention of the RN Coordinator on 11/10/10 at approximately 11:45 AM.

Interview with the RN Coordinator on 11/12/10 at 9:55 AM revealed they had stopped the Heparin administration on 11/10/10 before the 1:30 PM dose was to be administered.

During an interview on 11/12/10 at 10:00 AM, the LPN who co-signed the physician order dated 11/6/10, stated that she missed the opportunity to transcribe the order to the MAR, and it did not get done. The LPN added that she has already been counseled by the facility for her error.

415:12(m)(2)

K69 NFPA 101: COOKING EQUIPMENT

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 31, 2010

Cooking facilities are protected in accordance with 9.2.3. 19.3.2.6, NFPA 96

Citation date: November 12, 2010

Based on record review and staff interview during a Life Safety Code survey, one of one Kitchen Hood Extinguishing System was not inspected every six months. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Review of SEMI-ANNUAL INSPECTION REPORTS and Pre Engineered System Inspection Reports on 11/9/10 at approximately 8:30 AM revealed the facility's kitchen hood extinguishment system was inspected on 2/2/10 and on 9/2/10 in 2010.

Interview with the Director of Plant Operations revealed the outside vendor that inspects the facility's kitchen hood suppression system usually contacts the facility to schedule an inspect every six months and that he had realized that the contractor had not contacted the facility and when he contacted the contractor, the contractor was no-longer able to provide inspections for kitchen hood suppression systems. Further interview at this time with the Director of Plant Operations revealed the facility then contacted another vendor to inspect the kitchen hood suppression system.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1997 NFPA 101: 13-3.2.6, 7-2.3
2000 NFPA 101: 19.3.2.6, 9.2.3
1998 NFPA 96: 8-2

K33 NFPA 101: EXIT PARTITIONS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 31, 2010

Exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Citation date: November 12, 2010

Based on observation during a Life Safety Code survey, stairway exit doors were not properly maintained. Issues included stairway exit doors that would not self-close and latch into their frames. This affected one (Unit 4) of three resident units. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the Fourth Floor on Unit 4 on 11/8/10 at approximately 9:21 AM revealed the South stairway exit door near resident room #415 would not self-close and latch into its frame.

2. Observation on the Fourth Floor on Unit 4 on 11/8/10 at approximately 9:37 AM revealed the Dining room stairway exit door would not self-close and latch into its frame.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-3, 13-3.1, 13-3.1.2
2000 NFPA 101: 19.3, 19.3.1, 19.3.1.2

K29 NFPA 101: HAZARDOUS AREAS - SEPARATION

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 31, 2010

One hour fire rated construction (with hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Citation date: November 12, 2010

Based on observation during a Life Safety Code survey, hazardous area doors were not properly maintained. Issues included hazardous area doors that would not self-close and latch into their frames. This affected two (Units 3, 4) of three resident units and one (First Floor) of one Service corridor. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the Fourth Floor on Unit 4 on 11/8/10 at approximately 9:26 AM revealed the door to the UTILITY ROOM would not self-close and latch into its frame. Also at this time observation revealed this room contained an approximate 32 gallon soiled linen receptacle and an approximate 108 gallon trash receptacle.

2. Observation on the Third Floor on Unit 3 on11/8/10 at approximately 10:06 AM revealed the door to the UTILITY ROOM would not self-close and latch into its frame. Also at this time observation revealed this room contained an approximate 32 gallon and an approximate 44 gallon soiled linen receptacle and an approximate 108 gallon trash receptacle.

3. Observation on the First Floor Service corridor on 11/8/10 at approximately 11:11 AM revealed the door to the Laundry Soiled room would not self-close and latch into its frame.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-3.2, 13-3.2.1
2000 NFPA 101: 19.3.2, 19.3.2.1

K75 NFPA 101: WASTEBASKETS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: December 31, 2010

Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5

Citation date: November 12, 2010

Based on observation during a Life Safety Code survey, storage of soiled linen receptacles was not properly maintained. Issues included soiled linen receptacles that were stored in a room in which the receptacles capacity exceeded 0.5 gallons per square foot and/or a soiled linen receptacle with a capacity greater than 32 gallons was stored in a room that was not protected as a hazardous area. This affected two (Units 2, 4) of three resident units. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the Fourth Floor on Unit 4 on 11/8/10 at approximately 9:23 AM revealed the door to the HOPPER ROOM located near resident room #417 would not self-close and latch into its frame. Further observation at this time revealed this room contained an approximate 32 gallon soiled linen receptacle and an approximate 22 gallon soiled linen receptacle and the room was approximately six feet long by approximately three feet wide.

2. Observation on the Second Floor on Unit 2 on 11/8/10 at approximately 10:39 AM revealed a 44 gallon soiled linen receptacle was stored in the SINK ROOM located across from resident room #201. Further observation at this time revealed the door to this room had a 20 inch long by 12 inch wide open, unsealed louver in the door and the room was approximately five feet long by approximately five feet wide.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-7.5.5
2000 NFPA 101: 19.7.5.5