St Catherine Laboure Health Care Center

epn Based on observation, record review and staff interview, the facility did not ensure that residents are free of any significant medication errors. One (Resident #11) of 13 residents reviewed for medications had issues involving the lack of transcription of a physician order for a medication dose reduction and lack of pharmacy notification of the new medication order. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #11 has diagnoses including hypertension (HTN), chronic obstructive pulmonary disease (COPD), heart failure and advanced renal insufficiency.

Review of a Physician Order dated 2/9/11 revealed an order to decrease Lasix (diuretic) to 40 milligrams (mg) daily. Further review of the same order revealed the order was signed as being received by a Registered Nurse (RN) and signed as transcribed by two Licensed Practical Nurses (LPNs).

Observation of the resident's blisterpak (package consisting of a clear plastic overlay affixed to a cardboard backing for protecting and displaying a product such as medication) that was currently in use revealed directions to give Lasix 40 mg twice daily. There was no documented evidence that pharmacy had been notified of the order to decrease the administration frequency to daily.

Review of the Medication Administration Record (MAR) dated 2/1/11 through 3/21/11 revealed that the 2/9/11 order for Lasix 40 mg daily was not transcribed onto the MAR.

During an interview on 3/21/11 at 2:30 PM, a Unit 3 RN stated that on 2/9/11 she received a physician order at the end of the shift to decrease Lasix 40 mg from twice a day to one time per day. The RN explained that it was the responsibility of the next shift to transcribe the orders.

When interviewed on 3/21/11 at 2:40 PM, the Director of Nursing (DON) verified that although the 2/9/11 order had been signed off by two LPNs, it had not been transcribed to the MAR. Review of a binder labeled Faxed (pharmacy name) Orders revealed no documented evidence that the new Lasix order had been faxed to the pharmacy. The DON then called the pharmacy and learned that the pharmacy had not been notified of the order.

During an interview on 3/22/11 at 9:00 AM, the Consultant Pharmacist stated he reviews each resident's record every month and verified the last time he reviewed Resident #11 was 2/6/11.

415.12(m)(2)

Based on observation, record review, resident and staff interview, the facility did not ensure that residents receive proper treatment and care for respiratory care. One (Resident #5) of one resident with a tracheostomy (surgical opening in the trachea) observed using humidified oxygen lacked a physician order for oxygen including liter flow, frequency of use, and/or humidification. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #5 has diagnoses including status post buccal (cheek or mouth) wall cancer with tracheostomy, and history of respiratory failure.

The resident was observed in bed on 3/21/11 from 7:50 AM through 9:40 AM with a humidified trach collar over the trach site which was set at 28 percent (%) with an oxygen flow meter set at 8 liters per minute.

Review of Physician's Orders dated 3/16/11 revealed no documented evidence of an order for oxygen including flow rate, frequency of use, and/or humidification percentage. Review of the Resident Care Plan with an admission date of 2/24/11 revealed no care plan for humidified oxygen for a resident with a tracheostomy.

Interview with the lead Respiratory Therapist on 3/22/11 at 9:15 AM revealed the resident was on 40% humidification in the hospital as of 2/24/11. It was verified with the Respiratory Therapist and Registered Nurse (RN) Charge Nurse at this same time that there was a lack of documented evidence including a physician order for oxygen, flow rate, frequency of use and/or titration (slow reduction) down to 28%. Interview with the resident on 3/21/11 at 9:45 AM revealed he only uses the humidification during the night.

415.12(k)(6)

Based on record review and staff interview, the facility did not ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Three (Residents #3, 6, 7) of six residents reviewed for range of motion (ROM - normal range of motion for a joint) lacked documented evidence range of motion was provided in accordance with therapy recommendations. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #6 was admitted on 9/18/07 with a diagnosis of degenerative joint disease. Review of the Resident Care Plan with a run date of 3/1/11 documented "ROM Program per PT (Physical Therapy) recommendation on the closet care plan". Review of the Resident Care Plan dated 9/19/07 through 11/3/10 documented a plan for passive range of motion (PROM - staff will move the joint through available ROM) to both lower extremities five times per week and hold both knees extension for approximately 30 seconds.

Review of the resident's Range of Motion Program Sheet revealed PROM was documented as provided 9 of 28 days in 2/11 and 6 of 22 days 3/11. Further review of the Range of Motion Program Sheet directed that the appropriate box on the form be initialed when the ROM is completed.

When interviewed on 3/21/11 at approximately 1:00 PM, the Physical Therapist stated Range of Motion Aides report to nursing not rehab. During an interview on 3/21/11 at 1:30 PM, the Registered Nurse (RN) Charge Nurse stated nursing is not monitoring range of motion, physical therapy does it.

When interviewed on 3/21/11 at 1:37 PM, the Director of Nursing (DON) stated nursing is to monitor if range of motion is done.

During an interview on 3/22/11 at 11:43 AM, the assigned Certified Nurse Aide (CNA) stated she did not know she had to do the range of motion when the Rehab Aide is scheduled off.

2. Resident #3 has diagnoses of Parkinson's disease and dementia. Review of the Minimum Data Set (MDS) with an assessment reference date of 2/25/11 revealed the resident's cognition is moderately impaired with limitations of both lower extremities.

Review of the Physical Therapy (PT) TC Discharge Summary dated 12/7/10 revealed the resident was being discharged from restorative therapy services secondary to meeting his functional potential. The note documented that the Registered Nurse (RN) ambulation program would be reinitiated to help maintain current status. A Physician's Order dated 12/8/10 documented D/C (discontinue) restorative PT services secondary to plateau progress.

Review of the "Restorative Activity Flow Record" "approach/prescription" revealed directions to ambulate 6 times per week for 15 minutes to be signed by the Range of Motion (ROM) Aide. Review of the Flow Record for 2/11 and 3/11 revealed the Flow Records were not signed as provided 6 times per week as prescribed. The week of 2/1/11 through 2/8/11 was signed twice; the week of 2/9/11 through 2/15/11 was signed four times; the week of 2/16/11 through 2/22/11 was signed five times; week of 2/23/11 through 3/1/11 signed five times; the week of 3/2/11 through 3/8/11 signed one time; week of 3//9/11 through 3/15/11 signed five times.

During an interview on 3/21/11 at 11:00 AM, the ROM Aide stated he is to sign the book when done with ROM or ambulation every day for each resident. He explained that when he is not on duty for the day the Certified Nurse Aides (CNAs) do the ROM and ambulation and are supposed to sign as done.

When interviewed on 3/21/11 at 2:00 PM, the RN Charge Nurse stated the Licensed Practical Nurses (LPNs) are supposed to review the CNA books for completeness and to make sure the duties are done each day. The charge nurses are supposed to check the books weekly.

Review of the policy and procedure entitled "Range of Motion" revised on 1/07 revealed that trained staff within the nursing and or rehabilitation department will carry out range of motion plan of care. The policy and procedure documented the staff will complete documentation for each resident receiving range of motion on a daily basis.

During an interview on 3/22/11 at approximately 10:30 AM, the CNA assigned to Resident #3 stated he is supposed to do the ROM and ambulation on the resident when the ROM Aide is not there. The CNA explained he is supposed to document that he did ROM but he did not know that he was supposed to document the ROM or ambulation as done until today.

3. Resident #7 has diagnoses of osteoarthritis and mental retardation. Review of the Minimum Data Set (MDS) dated 2/25/11 revealed the resident has bilateral lower extremity limitations in range of motion and no limitations of the upper extremities.

Review of a form entitled Range of Motion (ROM) Program dated March/April 2011 revealed a plan for active assistive range of motion (AAROM - staff provides hands on assistance to help move resident's joint through the available range. Staff to encourage resident participation) 5 times per week to both upper extremities and passive range of motion (PROM) to both lower extremities 5 times per week. Further review revealed lack of documented evidence the ROM was completed 5 times per week from 3/1/11 through 3/21/11.

When interviewed on 3/21/11 at 1:45 PM, the Unit 3 Registered Nurse (RN) Unit Manager stated that the ROM Aide should sign the book after performing ROM and further explained the Certified Nurse Aides (CNAs) should sign the book when providing ROM on the ROM Aide's day off.

415.12(e)(2)

Based on observation during a Life Safety Code survey, structural components of the facility were not properly protected from fire. Issues include structural steel beams located above the lay-in ceiling assembly that were not protected to meet minimum acceptable fire rated building construction classification. This affected two (Units Two, Three) of two 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. Observations on 3/20/11 from approximately 9:00 AM until approximately 3:00 PM revealed a lay-in ceiling assembly installed throughout Unit Two and Unit Three. Further observations during this same time revealed the facility is not fully sprinklered.

Observation above the ceiling tiles on Unit Two, closest to the Fire Barrier doors that separate D-Building and C-Building, on 3/22/11 at approximately 9:58 AM, revealed two unprotected structural steel beams that were each approximately eight feet long.

Observation above the ceiling tiles on Unit Three, closest to the Fire Barrier doors that separate D-Building and C-Building, on 3/22/11 at approximately 10:08 AM, revealed two unprotected structural steel beams that were each approximately eight feet long.

Per the 1999 edition of NFPA 220: (National Fire Protection Association) Standard on Types of Building Construction; non sprinklered buildings, constructed of non-combustible materials, that are over three stories tall, are required to have steel beams protected with a fire rated material of at least two hours. A review of facility blueprints, acquired during the 2009 Annual Standard Survey, revealed the building is constructed to meet construction type I (443). A type I (443) constructed building requires steel support beams be protected with a four hour fire rating. In order for the building to remain compliant with type I (443) construction the facility must protect these beams with a four fire rated material.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-1.6.2, 13-3.5.1, 1-3.6, 13-1.1.4.1
2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

Based on observation during a Life Safety Code survey, exit corridors were not separated from rooms due to the lack of corridor doors. This affected one (Ground Floor) of three resident use floors. 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 3/20/11 at approximately 1:45 PM revealed the exit corridor at the Ground Floor was not separated from the Hydrotherapy Room, the Rehab Reception area and the Physical Therapy rooms by corridor doors. There were two openings to the Physical Therapy room that lacked doors. The first opening was approximately twelve feet wide. The second opening was approximately ten feet wide. The opening to the Hydrotherapy room was approximately 40 inches wide. The opening to the rehab reception area was approximately six feet wide.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.6.3

Based on observation during a Life Safety Code survey, corridor walls were not complete from floor to ceiling-deck on one (Ground Floor) of three resident use floors. Issues include penetrations through corridor walls above the suspended ceiling tile assembly and incomplete walls above the suspended ceiling tile assembly. Per NFPA 101 (National Fire Protection Association) Life Safety Code, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings and they shall have a fire resistance rating of not less than 1/2 hour. 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 above the ceiling tiles at the Occupational Therapy room on the Ground Floor, on 3/22/11 at approximately 9:12 AM, revealed an approximate four inch diameter penetration with a three inch water pipe going through it, a six inch by ten inch penetration under an air duct and a ten inch by ten inch penetration with an electrical conduit going through it.

2. Observation above the ceiling tile at the HydroTherapy Room on the Ground Floor, on 3/22/11 at approximately 9:20 AM revealed an approximate three feet high by approximately 60 feet long area of incomplete corridor walls between the ceiling deck and the suspended ceiling tile assembly.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.6.1, 19.3.6.2.1

Based on observation during a Life Safety Code survey, hazardous areas were not properly protected. Issues include a door protecting a hazardous area that had a disconnected self closing mechanism. This affected one (Unit Two) of two resident units. This was a pattern with no actual harm with potential for more than minimal harm that is not immediately jeopardy.

The findings are:

1. Observation on 3/20/11 at approximately 12:06 PM revealed the door to the Clean Linen Room on Unit Two, closest to resident room #805, did not self close and latch. The self closing mechanism was in place, however, it was disconnected from the door frame and prevented the door from closing.

10 NYCRR 415.29(a) (2), 711.2(a) (1)
2000 NFPA 101: 19.3.2.1

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 3/24/10.

Based on observation during a Life Safety Code survey, oxygen cylinders were not properly stored. Issues include oxygen cylinders that were stored unsecured and a latching mechanism on a storage cabinet that did not function properly. This affected one (Unit Two) of two 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 Unit Two on 3/20/11 at approximately 12:19 PM revealed an unsecured D-sized oxygen cylinder stored in a carrying case, lying on its side, unsecured on the second shelf of a wire rack, approximately three feet above the floor.

2. Observation on 3/21/11 at approximately 11:56 AM revealed that a 24 cylinder capacity fire rated Oxygen Storage cabinet was stored in the corridor on Unit Two. At the time of this observation, the cabinet door was manually unlocked and opened. The cabinet contained 20 E-sized oxygen cylinders. When the door was released to test the door's self closing mechanism, the door did not self latch. Per the 2005 edition of NFPA 99, (National Fire Protection Association) 12 E-sized oxygen cylinders can be stored at locations open to the corridor. Because the cabinet door did not self close and latch, the number of oxygen cylinders stored open to the corridor exceeded 12 cylinders.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.2.4
1999 NFPA 99: 4-3.1.1.1,
Centers for Medicare and Medicaid services Survey & certification letter S&C-07-10
2005 NFPA 99: 9.4.3

Based on observation, record review and staff interview during a Life Safety Code survey, fire extinguishers were not current for an annual inspection. This affected the Ground Floor Main Kitchen and one (Unit Three) of two resident units. This was a pattern with no actual harm with potential for more than minimum harm that is not immediate jeopardy.

The findings are:

1. Observations on 3/20/11 from approximately 10:30 AM until 11:30 AM revealed that three fire extinguishers located within the Ground Floor Main Kitchen were not current for an annual inspection. A review of the attached inspection tags on each of the three fire extinguishers revealed monthly inspections were conducted from 2/10 through 3/11. The annual inspection was due 1/11.

A review of fire extinguisher inspections records on 3/22/11 revealed 381 fire extinguishers in both the Skilled Nursing facility and Hospital were inspected 1/27/11 with 27 fire extinguishers needing service. This inspection record did not identify specific fire extinguishers targeted for service. An interview with the facility's Maintenance Director on 3/22/11 at approximately 1:40 PM revealed fire extinguishers requiring service should have been pulled from service and replaced with spare fire extinguishers.

2. Observations on 3/20/11 at 11:56 AM revealed the fire extinguisher located on Unit Three closest to resident room #819 was not current for an annual inspection. A review of the attached inspection tag on the fire extinguisher revealed monthly inspections were conducted from 2/10 through 3/11. The annual inspection was due 1/11. A review of fire extinguisher inspections records on 3/22/11 revealed 381 fire extinguishers in both the Skilled Nursing facility and Hospital were inspected 1/27/11 with 27 fire extinguishers needing service. This inspection record did not identify specific fire extinguishers targeted for service. An interview with the facility's Maintenance Director on 3/22/11 at approximately 1:40 PM revealed fire extinguishers requiring service should have been pulled from service and replaced with spare fire extinguishers.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.5.6, 9.7.4.1
1998 NFPA 10: 4-3, 4-4

Based on observation during a Life Safety Code survey, a vertical opening was not properly protected. Issues include laundry chute doors that did not close and latch into their door frames. This affected two (Units Two, Three) of two 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 3/21/11 at approximately 9:36 AM revealed the Unit Three Soiled Laundry Chute door, located in Laundry Chute Room LC-11, did not self close and latch when tested.

2. Observation on 3/22/11 at approximately 9:39 AM revealed the Unit Two Soiled Laundry Chute door, located in Laundry Chute Room LC-10, did not self close and latch when tested.
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10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA: 19.3.1.1, 8.2.5, 8.2.5.1

Based on observation, record review and staff interview during a Life Safety Code survey, the audible fire alarm devices did not sound when activated from a manual pull station. This affected one (Ground Floor) of three resident use floors. 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 of a facility conducted fire drill on 3/21/11 at approximately 10:00 AM revealed that when the manual pull station was pulled by a staff person from the onsite Adult Day Health Care Program, the fire alarm bells on the Ground Floor did not sound an audible alarm. At this time, the audible alarm bells were observed to be non-working at the Occupational Therapy room, the Physical Therapy Room, the Adult Day Care Program Room, the Exit Corridor and the Main Entrance Reception Area. The audible alarm did work at the MRI (Magnet Resonance Imaging) Suite.

A review of Fire Alarm Inspection Reports, on 3/21/11 at approximately 2:15 PM revealed that during the Fire Alarm Inspection conducted by an independent inspection company during 11/10, a total of twelve fire alarm audible bell devices on the First (Ground) Floor did not work. Under the section "Note" on the Fire Alarm Inspection report it stated "All bells on the first floor "D" building (1974) did not sound. Service needed to repair or replace with new units. Old bells may no longer be available". The skilled nursing unit is located in the "D" building and was constructed during 1974.

An interview with the facility Maintenance Director on 3/22/11 confirmed that the only audible alarm bell that sounded was in the MRI Suite. Further interview revealed the Fire Alarm Service company was onsite to trouble shoot and make repairs.

Observation on 3/22/11 at approximately 2:25 PM confirmed the Fire Alarm Audible Alarm Bells on the Ground Floor were working.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 9.6.1.4
1999 NFPA 72: 7-3, 7-4