Fort Hudson Nursing Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Edward, New York.
- Location
- 319 Upper Broadway, Fort Edward, New York 12828
- CMS Provider Number
- 335300
- Inspections on file
- 12
- Latest survey
- December 6, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fort Hudson Nursing Center Inc during CMS and state inspections, most recent first.
The facility failed to inspect and test elevators in Building #1 according to required intervals, lacking documentation for inspections and necessary repairs. The administrator believed inspections were done but could not provide evidence. The facility also did not fully implement the Electronic Plan of Correction by the Credible Allegation Date, leading to a citation.
The facility failed to maintain adequate staffing levels, resulting in delayed call light responses and resident grievances. From December 1 to December 5, 2024, multiple shifts and units were understaffed, with significant shortages of CNAs and LPNs. Residents reported long wait times for assistance, and staff interviews confirmed that understaffing slowed care delivery. The Assistant Director of Nursing acknowledged the challenges in meeting call light response expectations due to the high number of residents requiring mechanical lifts.
The facility did not maintain exits in compliance with NFPA 101 Life Safety Code, as exit discharges in the G-wing and S-wing were not marked to clearly indicate the direction of egress travel to a public way. This was observed during a recertification survey, and the facility's administrator acknowledged the issue.
Exits in two wings were obstructed by snow and padlocks, impeding their use as required by NFPA 101 Life Safety Code. Maintenance staff shortages delayed snow removal, and staff were not trained to open the padlocks. The charge nurse was unaware of how to operate the padlock, highlighting a lack of preparedness in emergency situations.
A recertification survey revealed that the automatic sprinkler system was not installed under a cloth canopy attached to Building #3, as required by NFPA standards. The canopy, over 20 feet in length, lacked documented evidence of being fire-retardant. The facility's administrator mentioned that the canopy was installed in 2020 and they are seeking documentation from the vendor about its fire-retardant properties.
The facility did not maintain smoke barriers according to NFPA 101 standards. A hole in the G-wing east smoke barrier wall was filled with insulation but lacked proper fire protection. The Maintenance Supervisor acknowledged the issue and planned to address it.
Two residents were observed self-administering medications without documented assessments or physician orders, contrary to the facility's policy. One resident had a Proventil inhaler at their bedside, and another changed their oxygen tank and set the flow rate independently. Staff interviews revealed a lack of adherence to the facility's Medication Self-Administration Policy, which requires assessments and care plans for self-administration.
A resident's care plan in the facility failed to document the use of oxygen and nebulizer treatments, despite the resident being observed with oxygen and having orders for these treatments in the electronic health record. The resident, who was cognitively intact and had diagnoses including hypertension and atrial fibrillation, did not have these treatments included in their care plan as required by facility policy. Staff interviews confirmed the oversight, with the ADON acknowledging the expectation for the oxygen to be documented.
Two residents in the facility were found to have as-needed psychotropic medication orders without specified stop dates, contrary to policy. One resident received lorazepam for agitation multiple times without an end date, while another had an indefinite order for Risperidone despite a recommendation for a stop date. The Nurse Practitioner acknowledged the requirement for time-limited orders but did not implement it.
A resident's dietary preference to discontinue a collagen supplement, supported by a dietician's recommendation and physician's order, was not followed for 35 days due to an oversight in updating the electronic medical record. The RN unit manager acknowledged the error, and the DON expected compliance with signed dietary recommendations.
The facility failed to maintain accurate medical records for three residents, with inconsistent documentation of incontinence care, meal consumption, and supplement intake. Staff interviews revealed that documentation was not always completed in real-time, and there was confusion about documentation procedures. The facility's practices did not align with the expectations for accurate record-keeping.
The facility failed to maintain accurate and complete medical records for three residents, leading to deficiencies in documentation of care provided. A resident's incontinence care was not documented as required, and two other residents had incomplete documentation of meals, supplements, and snacks. Staff interviews revealed inconsistencies in documentation practices, and the Assistant Director of Nursing acknowledged a documentation issue.
The facility's emergency preparedness plan was found lacking provisions for earthquake, flood, or nuclear disaster, as required by New York State regulation. This deficiency was identified during a recertification survey, with no documented evidence of these provisions. The administrator acknowledged the oversight and planned to address it.
Elevator Inspection and Testing Deficiency
Penalty
Summary
The facility failed to inspect and test the elevators in Building #1 according to the required 12-month and 5-year intervals as specified by the American Society of Mechanical Engineers booklet A17-1 Safety Code for Elevators and Escalators 2004 Edition. Specifically, there was no documented evidence that the G Wing 1 and G Wing 2 elevators, the service elevator, and the dumbwaiter were inspected and tested during the years 2022 and 2024. Additionally, necessary repairs, such as the emergency phone and lighting circuit repairs for the G Wing 1 elevator, were not documented as completed. The service elevator also required a rupture test, which was not documented as conducted. During interviews, the facility's administrator expressed belief that the inspections and tests had been conducted but was unable to provide the necessary documentation. The facility also failed to ensure that the Electronic Plan of Correction was fully implemented by the Credible Allegation Date, as there was no evidence that the G Wing 1 elevator emergency phone was repaired or that a rupture test was conducted on the service elevator. This lack of documentation and failure to adhere to the required testing schedule led to the citation during the recertification survey.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 1. Elevator inspection reports demonstrate completion every six months for the past three years for each elevator (4). Proposal for all outstanding repairs accepted on 12/10/24 and is scheduled to be completed by P(NAME) completion date of 2/3/25. 2. No other elevators exist in the building. 3. Inspection and testing schedule to be developed to assure compliance with frequency, with all results provided directly to the Director of Plant Operations for review to assure recommended repairs are addressed in a timely manner. 4. Inspection, testing and repair information will be provided to the Quality Assurance/Performance Improvement Committee on a quarterly basis for one year, with frequency to be reassessed after one year based on overall compliance with frequency and repair follow up. Responsible Party: Director of Plant Operations
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, compromising their safety and well-being. From December 1 to December 5, 2024, the facility did not meet its minimum staffing levels for Certified Nursing Aides (CNAs) and Licensed Practical Nurses (LPNs) across multiple shifts and units. This staffing shortage was evidenced by delayed call light response times, resident grievances, and complaints about low staffing levels. Observations during this period showed significant delays in call light responses, with some residents waiting over 50 minutes for assistance. The facility's staffing plan, as per the assessment dated August 28, 2024, outlined specific numbers of full-time employees required per shift. However, records from December 1 to December 5, 2024, indicated consistent shortages in staffing across various wings and shifts. For instance, on December 1, 2024, the evening shift was missing several CNAs and LPNs across different wings, and similar shortages were noted on subsequent days. These deficiencies were further corroborated by resident grievances filed between February and September 2024, highlighting issues such as long wait times for assistance, inadequate toileting support, and poor care due to insufficient staffing. Interviews with residents and staff further illustrated the impact of these staffing shortages. Residents reported long wait times for assistance, sometimes exceeding an hour, particularly during meal times when staff were occupied with other residents. Staff interviews revealed that understaffing led to slower care delivery, as staff from other units, unfamiliar with the residents, had to cover shifts. The Assistant Director of Nursing acknowledged the challenges in meeting call light response expectations, citing the high number of residents requiring mechanical lifts and the lack of adequate space to accommodate them. These factors collectively contributed to the facility's failure to maintain adequate staffing levels, directly affecting the quality of care provided to residents.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. In the absence of resident-specific corrections to be made, the Administrator and/or Director of Nursing will meet with the Resident Council to review this Plan of Correction and request feedback. 2. All Customer grievances related to call bell response times over the last 12 months will be reviewed for trend identification to determine if there are root cause issues or common time/shifts/units, etc. If identified, focused action plans will be implemented. 3(a). The following strategies focused on staff recruitment and retention will continue to be implemented and continually adjusted based on response to address overall staffing levels. a. Aggressive recruitment campaign, including sign on bonus, referral bonus, tuition reimbursement, etc., with addition on 1/1/25 of new social media contract service. NOTE - agency nursing, including travel nurse resources are extremely scarce in rural areas. Several contracts are in place but unable to provide actual supplemental staff. Staffing requests remain pending and unfilled. Facility will review, screen and onboard agency staff that contracted agency finds. Current staff will continue to be offered significant shift bonuses (Up to $25 per hour differentials) for hard to fill shifts. b. Continued implementation of Nurse Aide training program, including evening classes (grant funded). c. Continued mentorship programs for newly hired Certified Nursing Assistants and Licensed Practical Nurses. d. Continued tuition reimbursement program (currently sponsoring 3 Licensed Practical Nursing students’ full tuition plus stipend for living expenses while in school). e. Incentive programs for longevity, attendance and other positive promotion strategies. 3(b). The following strategies will focus specifically on call light response times: a. Educational awareness program to be implemented for all clinical and support staff emphasizing the importance of call light response promptness. b. Review and revision of morning care routines for residents identified as consistently requesting assistance at predictable times with care plan adjustments as determined appropriate. c. Incorporate all staff, including ancillary department employees, with the responsibility to respond to call bells to address those issues and request within their scope of abilities, and communicate to nursing specific needs that may exist. d. No specific policy changes are indicated as this portion of the Plan of Correction focuses on staff awareness and education, combined with objective assessment of care delivery routines. 3(c). The Facility Assessment will be reviewed and updated to more clearly assess and articulate: a. Optimal staffing levels vs. minimally appropriate levels based on acuity and related variables required for appropriate resident care. b. Appropriate staffing adjustments based on census (as current Assessment and basis for deficiency is based on 100% occupancy but facility is not operating at that level). c. Recognition of support staff, reassigned staff, and other resources routinely accessed but not evident on daily staffing sheets. 4. Overall staffing levels by unit will be summarized daily and compared to the Facility Assessment optimal and minimally appropriate levels. Summarized and reported to Quality Assurance & Performance Improvement Committee monthly for six months. Total number of new hires and terminations for Certified Nursing Assistants and Licensed Practical Nurses, and overall turnover rates to be summarized monthly and reported to Quality Assurance & Performance Improvement for six months. No fewer than 5 visual observation audits (call bell response time) on different units and/or different times of day will be conducted weekly to measure call light response time. Audits will occur weekly for 3 months, followed by 10 audits per month for three months. Audit results to be reviewed by Quality Assurance & Performance Improvement Committee, which may extend or increase frequency based on results. Responsible Party: Administrator
Failure to Mark Exit Discharges in Accordance with NFPA 101
Penalty
Summary
The facility failed to maintain exits in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition, Sections 19.2.7 and 7.7, as observed during a recertification survey. Specifically, the G-wing and S-wing exit discharges in buildings #1 and #3 were not marked to clearly indicate the direction of egress travel from the exit discharge to a public way. This deficiency was identified during observations conducted on December 5, 2024, at 2:13 PM. During an interview at 3:07 PM on the same day, the facility's administrator acknowledged the issue and indicated that the facility would assess all exit discharges and install the required signage.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. Signage installed at exit discharge locations directing travel to the public way (Route 4). (NOTE – either direction (left/right) leads to the public way) 2. All other exit discharge locations for Building #1 inspected, signage placed where necessary. 3. Maintenance staff will be provided education in the form of written notice about the requirement for directional signage at exit discharges to a public way, with signature attesting to receipt and understanding. 4. The presence of signage at exit discharge locations will be audited once per month for six months to assure it is properly located, with the results reported to Quality Assurance/Performance Improvement committee. Responsible Party: Director of Plant Operations
Obstructed Exits Due to Snow and Padlocks
Penalty
Summary
Exits in Building #1 and Building #3 were not maintained in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. Specifically, the G-wing and S-wing exit discharges were obstructed with snow and had padlocks on the gate doors, which impeded their full instant use. During observations, it was noted that the northwest and southwest exit discharges of the G-wing, as well as the four exit discharges from the S-wing, were blocked by snow. Additionally, the padlocks on the gate doors were not easily operable, as staff were not trained on how to open them. Interviews revealed that several maintenance staff were on sick leave, which contributed to the delay in clearing the snow from the exit discharge sidewalks. The Maintenance Supervisor indicated that the padlocks were designed to be twisted and broken off, but there was no documented evidence that staff were trained on this procedure. The G-wing charge nurse was unaware of how to open the padlock on the exit discharge gate door. The Administrator acknowledged the issue and mentioned plans to address the obstructions, but the report focuses on the existing deficiency and the lack of immediate action to ensure the exits were free of obstructions.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. The accumulated snow (measuring 0ö to 2ö) from the preceding weather event (ending 7 a.m.) was cleared by 3 p.m. This was the last section to be cleared following a full-day continuous effort. Exterior fence gate break-away padlocks were removed. 2. All other paths of egress, including all driveways, parking lots, etc. had been cleared as part of the full day response; identified areas were the last to be addressed but not overlooked. All other exterior fence gates were inspected and break-away locks removed where found. 3. All maintenance staff responsible for snow clearing will be made aware of the requirement to keep all areas of egress cleared of any obstruction; and to notify the Director of Plant Operations if additional resources are necessary during or following a snow event (when snow is the potential impediment). This information will be provided in written form by the Director of Plant Operations, with signature acknowledging receipt and understanding. Maintenance of egress routes will be included in new employee onboarding education. Fence gates will remain free of locking devices – alternative gate hardware requiring two hand function (non-locking) will be evaluated for potential installation. 4. Following any snow event for the next 3 months, egress paths will be visually inspected by the Director of Plant Operations (or as delegated) on no less than 2 hour intervals during and after the event to ensure paths are cleared in a timely manner. On a monthly basis for six months, an audit of all discharge exits will be inspected on a weekly basis to assure no obstructions exist. The results of this audit and the snow clearing audit will be reported to the Quality Assurance/Performance Improvement committee monthly. Responsible Party: Director of Plant Operations
Deficiency in Sprinkler System Installation Under Canopy
Penalty
Summary
During a recertification survey, it was observed that the automatic sprinkler system was not installed in accordance with the National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.15.1. Specifically, automatic sprinkler protection was absent at an exit discharge under a cloth canopy attached to Building #3. The canopy, which is greater than 20 feet in length, was found at the exit discharge nearest to the basement of Building #1. There was no documented evidence that the canopy fabric is fire-retardant. The facility's administrator stated that the canopy was installed in 2020 and they are in the process of contacting the vendor to obtain documentation regarding the fire-retardant nature of the canopy fabric.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. Canopy attached to Building #3 to be replaced with approved fire-retardant material. 2. Other building areas where a canopy is in use and subject to this standard will be inspected to ensure appropriate fire-retardant product is in use where exterior sprinklers do not exist. 3. Documentation will be maintained demonstrating fire-retardant materials are in use when installed. 4. Once the correction is made, no further monitoring is indicated. Completion status will be reported to the Quality Assurance/Performance Improvement committee. Director of Plant Operations
Failure to Maintain Smoke Barriers as per NFPA 101
Penalty
Summary
The facility failed to maintain smoke barriers in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition. Specifically, the G-wing east smoke barrier wall in Building #1 was not continuous from the floor to the underside of the roof and through all concealed spaces, and the fire-resistance rating was not maintained as required. During observations, a 12-inch by 12-inch hole in the smoke barrier wall was found filled with insulation but not fire-protected. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged the issue and stated that they would address the fire sealing of the space in the G-wing smoke barrier wall.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. G wing east smoke barrier wall penetration will be sealed using appropriate fire seal. Due to the location of this area, it is not accessible for hand-application and specialized equipment is required. NOTE – this penetration was from original construction and is located above a series of pipes and conduits offering no means of direct access. 2. All smoke barrier walls in building #1 (identified as G and D wings) will be inspected to identify any other penetrations lacking appropriate fire protection. 3. All maintenance staff will be informed of the requirements for smoke walls and fire protection sealant in written form, with signature attesting to receipt and understanding. Existing standards for new work resulting in penetrations will be included in education. 4. Director of Plant Operations will verify all smoke barrier walls have been visually inspected and report the findings to Quality Assurance/Performance Improvement committee. New work resulting in penetrations to smoke walls will be visually inspected at completion; any remaining penetrations will be reported through Safety Committee. Responsible: Director of Plant Operations
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents could safely self-administer medications when clinically appropriate, as evidenced by observations and record reviews during a recertification survey. Two residents, identified as Resident #35 and Resident #168, were involved in this deficiency. Resident #35, who has diagnoses including Spina Bifida, morbid obesity, and paraplegia, was observed with a Proventil inhaler on their overbed table without documented evidence of an assessment for their ability to self-administer medications. Additionally, there was no physician order allowing self-administration, and the care plan did not include documentation for self-administration. Despite a physician order indicating the inhaler could be kept at the bedside, the Medication Administration Record stated that medications should not be left at the bedside, highlighting a discrepancy in the facility's adherence to its own policies. Resident #168, with diagnoses of chronic obstructive pulmonary disease, end-stage renal disease, and chronic systolic heart failure, was observed changing their oxygen tank and setting the flow rate independently. Similar to Resident #35, there was no documented assessment or physician order for self-administration of medications, and the care plan lacked documentation for self-administration. Interviews with facility staff, including a Certified Nurse Aide, LPN, and RN, revealed that residents were not permitted to change their own oxygen tanks or adjust flow rates, as oxygen is considered a medication. The staff acknowledged that residents should be assessed for self-administration and self-regulation of medications, but no such assessment was documented for Resident #168. The facility's Medication Self-Administration Policy, dated September 2017, requires staff and practitioners to assess each resident's mental and physical abilities to determine the appropriateness of self-administering medications. However, the facility failed to adhere to this policy for both residents involved in the deficiency. Interviews with the Assistant Director of Nursing confirmed that a care plan and assessment should be in place for residents to self-administer medications, but these were not completed for the residents in question.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Residents #35 and #168 were assessed for safety in self-administering associated medication (inhaler and oxygen respectively) with medical orders provided if indicated and care planned accordingly. #35 medication is no longer left at bedside. #168 is not allowed to self-regulate oxygen or change tank per facility policy. 2. All resident medication administration records will be reviewed to identify orders which allow medication(s) to be left at bedside, and corresponding self-administration assessments. No other residents were identified which had medications at bedside without corresponding assessments and medical orders. All residents on oxygen reviewed to identify any resident that was independently changing supply or adjusting flow rates independently – no other residents identified. 3. All medical providers and Registered Nurses (RNs) will be re-educated on facility policy regarding self-administration of medication for residents, including assessment, medical orders and care planning requirements. No policy changes were indicated following review. 4. All new medication orders stating “self-administration” identified during the pharmacist’s monthly medication regimen review process will be reviewed to assure appropriate protocols (including assessment, medical order and care plan) are followed. Review to consist of 100% new orders for 3 months; and no less than 50% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance and Performance Improvement Committee based on overall compliance with policy. Responsible Party: Director of Nursing
Deficiency in Comprehensive Care Plan Documentation
Penalty
Summary
The facility failed to ensure the development and implementation of a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the care plan for a resident did not document the use of oxygen and a nebulizer, despite the resident being observed with oxygen in place and having an order for oxygen and nebulizer treatments in the electronic health record. The resident was admitted with diagnoses including hypertension, paroxysmal atrial fibrillation, and supraventricular tachycardia, and was cognitively intact, able to understand and be understood by others. The facility's policy required a written care plan to be developed upon admission and reviewed within 48 hours, with completion by the first care plan meeting within 14 days. However, the care plan dated 11/21/2024 lacked documentation of the resident's oxygen use, despite an order for continuous oxygen and nebulizer treatments being present in the electronic health record. Interviews with facility staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed the absence of the oxygen care plan and indicated that registered nurse unit managers were responsible for updating care plans. The Assistant Director of Nursing acknowledged the expectation for the oxygen to be included in the care plan.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #334 care plan was updated to include resident’s use of oxygen and a nebulizer. 2. All current resident medication administration records will be reviewed for orders for oxygen and/or nebulizer treatments and their care plans were reviewed to ensure comprehensive care plans are in place. New admissions with oxygen orders will have their care plan reviewed as described in #4 below. 3. All Registered Nurses will be re-educated on the requirement and associated time frames to develop care plans for oxygen and/or nebulizer treatments. No changes to the relevant policies were indicated. 4. All new physician orders [REDACTED]. 100% review of new orders for 3 months; no less than 75% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance & Performance Improvement Committee based on audit results (actual threshold of compliance will influence the decision to continue audits beyond 6 months). Responsible Party: Director of Nursing
Failure to Implement Time-Limited PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was managed and monitored to promote or maintain their highest practicable mental, physical, and psychosocial well-being. Specifically, two residents were identified during a recertification survey as having as-needed psychotropic medication orders without specified stop dates, contrary to the facility's policy and procedure. Resident #59, who was admitted with dementia, anxiety disorder, and depression, had an order for lorazepam to be administered as needed for agitation, but the order lacked an end date. The medication was administered multiple times over November and December 2024 without a specified stop date. Similarly, Resident #86, also diagnosed with dementia, anxiety disorder, and depression, had an order for Risperidone to be given as needed for agitation/anxiety, with the order documented as indefinite. Despite a pharmacy consultant's recommendation to apply an end date, the Nurse Practitioner disagreed, citing concerns about the medication not being renewed. This lack of adherence to the requirement for time-limited as-needed psychotropic medication orders was acknowledged by the Nurse Practitioner during an interview, indicating awareness of the Centers for Medicare and Medicaid requirement.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Residents #59 and #86 Medication Administration Orders were corrected to ensure 14 day limits were included as required for their as-needed (PRN) [MEDICAL CONDITION] medication orders. 2. All current resident medication administration orders were reviewed for as needed [MEDICAL CONDITION] medications to ensure 14 day stop dates are in place. 3. All medical providers re-educated on requirement that [MEDICAL CONDITION] medications given on an as needed basis must have an end date specified in the order not to exceed 14 days, along with other policy requirements. All nurses who have the potential to enter orders (Registered Nurses, Licensed Practical Nurses) will be re-educated on the requirements in [MEDICAL CONDITION] medication order entry. 4. All new orders for “as needed” [MEDICAL CONDITION] will be audited weekly from medical provider order summary, in addition to the pharmacist’s drug regimen review process (on admission and monthly) which will identify any non-conforming order. Any pharmacist finding and recommendation pertaining to as needed [MEDICAL CONDITION] medications will be brought to the direct attention of the Director of Nursing or her designee. Results of the reviews will be reported to the Quality Assurance & Performance Improvement Committee; 100% of new as needed [MEDICAL CONDITION] orders will be reviewed for compliance with policy for 6 months; frequency of audit to be re-evaluated at 6 months by Quality Assurance & Performance Improvement Committee based on audit results. Responsible Party: Director of Nursing
Failure to Discontinue Collagen Supplement as Ordered
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences and physician's orders were followed, resulting in a deficiency. Specifically, a resident had a dietician's recommendation, signed by a physician, to discontinue a collagen supplement. Despite this, the supplement continued to be administered for 35 days after the recommendation. The resident was cognitively intact and had expressed a desire to discontinue the supplement, which was agreed upon by the provider. However, the order to discontinue was not processed in the electronic medical record, leading to continued administration. The deficiency was identified during a recertification survey, where it was found that the order to discontinue the collagen supplement was only present in the paper record and not updated in the electronic system. The Registered Nurse unit manager responsible for processing new orders acknowledged the oversight and confirmed that the order was missed in the electronic record. The Director of Nursing stated that they expected dietary recommendations signed by the provider to be followed and discontinued as ordered.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Resident #82 Medication Administration Record [REDACTED]. Responsible Registered Nurse self-identified that when she had followed up with the resident, the resident had clarified they didn't ask for a discontinuation of the Collagen order, but rather a change in administration time. This Registered Nurse followed through on the resident's request, but failed to update the medical provider of this resident's request, nor get a refreshed order based on the resident's request, as defined in policy. 2. All resident records on the unit (B wing) where the Registered Nurse was entering medical orders and made the above error to be reviewed to ensure any written recommendations made by an ancillary service during the prior three months (including Registered Dietician, therapy, psychiatry, or specialist consultants--Orthopedics, Cardiology, Neurology) to ensure there is a corresponding medical order that is properly executed. 3. All licensed nurses responsible for transferring recommendations to medical orders will be provided with a policy overview of the procedure for transferring clinical recommendations to properly executed medical orders. There is no policy change indicated as this deficiency is directly related to a single order that was not completed by one employee, who self-identified the error. 4. On a daily basis (defined as every day), the night shift licensed nurse will conduct a 100% audit (visual review) of all new orders obtained during the prior 24 hours, to include written recommendations which are to be transferred to a written medical order. The results will be provided to the Director of Nursing (or designee) daily (which means daily; or the next day after a weekend). Errors, if identified, are raised to the attention of the Registered Nurse Supervisor who is in communication with the Director of Nursing or her designee and will be addressed immediately, or at the most appropriate time based on the nature of the error found (i.e. prior to the advent of additional error). A summary of the audit results will be provided to Quality Assurance & Performance Improvement monthly, with frequency to be re-evaluated after six months. As the nightly audit is being reviewed by the Director of Nursing or her designee (the assistant director of nursing) on a daily, or near daily basis, monthly reporting to Quality Assurance and Performance Improvement Committee is appropriate. In the event the Director of Nursing identifies trends or clusters of errors, correction actions will be implemented immediately. Responsible Party: Director of Nursing
Inconsistent Documentation of Resident Care
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for three residents. For one resident, the facility did not document incontinence care as required. The resident had a care plan that included a toileting schedule, but the documentation was inconsistent, with some entries missing or duplicated. Interviews with staff revealed that documentation was not always completed in real-time, and there was confusion about where and how to document the care provided. For two other residents, the care provided by Certified Nurse Aides was not consistently documented, particularly regarding the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. The care plans for these residents included specific dietary interventions due to their medical conditions, such as severe protein-calorie malnutrition and potential for weight loss. However, the documentation of meal and supplement intake was incomplete or missing on several occasions, indicating a failure to accurately record the care provided. Interviews with nursing staff highlighted a lack of oversight and verification of documentation completion. Licensed Practical Nurses and Registered Nurses were expected to check the electronic medical record dashboard for task completion, but this was not consistently done. The Assistant Director of Nursing acknowledged the documentation issues, emphasizing the expectation that care should be documented as ordered, but the facility's practices did not align with these expectations.
Deficiency in Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, leading to deficiencies in documentation of care provided. For one resident, the facility did not document incontinence care as required. The resident had a care plan that included a toileting schedule, but the task log showed inconsistencies and missing entries for when care was performed. Interviews with staff revealed that documentation was not always completed in a timely manner, and there was confusion about where and how to document the care provided. Two other residents also experienced issues with documentation. Certified Nurse Aides did not consistently document the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. The care plans for these residents included specific dietary interventions, but the Point of Care Response History showed incomplete or missing documentation for several dates. Interviews with nursing staff indicated that there was an expectation for documentation to be completed, but it was not consistently checked or verified. The lack of proper documentation was acknowledged by the facility's Assistant Director of Nursing, who noted that there was a documentation issue. The failure to accurately document care provided to residents, including toileting and nutritional intake, was a significant deficiency that was identified during the recertification survey. This deficiency highlights the need for improved processes and oversight to ensure that all care provided is accurately recorded in accordance with professional standards.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Residents #21, #144, and #171 documentation will be reviewed by the Registered Nurse Manager, with a summary assessment documented on their toileting or nutritional intake (based on nature of identified missing documentation). Missed documentation of this type cannot be accurately recreated in a retrospective manner, and a summary of the resident's status based on the Registered Nurse assessment is appropriate to substitute in this manner. 2. All residents on a specific toileting program or identified as high risk nutritionally requiring meal intake monitoring will be reviewed to assure their plan is appropriate and the documentation is substantially complete. If found to be insufficient, a summary assessment will be conducted and documented on their toileting or nutritional status by the Registered Nurse. See further explanation under #1 above. 3. The following corrective measures will be implemented: a. Toileting documentation – Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements of clinical task documentation. Within the last hour of each scheduled shift, the Licensed Practical Nurse (charge nurse) will review all task documentation that is outstanding via electronic reporting and communicate findings to assigned CNAs. Information will be provided to Registered Nurse Manager, who will provide ongoing counseling and education as necessary on the units. b. Intake Recording – Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements for intake monitoring and documentation. Hand-held devices (tablets) will be deployed in the dining areas for documentation at each meal. Charge Nurse will maintain a list of residents on intake monitoring, validating documentation completeness and accuracy during and after each meal. No documentation policy changes were indicated. In the event the charge nurse is unable to perform the audits at the end of their shift, they will first do a verbal check in with the aides; and second, if necessary, will report to their Nurse Manager or Supervisor they were unable to complete this task. 4. Registered Nurse Unit Managers will audit (visually review of documentation in electronic health record) compliance for no less than 4 days per week (using a 24 hour report) for 3 months, and 2 days per week for 3 months to determine compliance, with results reported monthly to Quality Assurance & Performance Improvement. In the event any particular unit(s) find continuing compliance issues, the findings will be reviewed with the Director of Nursing (or designee) to determine if increasing frequency of review is indicated (vs. isolated performance issue). Frequency of audits will be reevaluated after 6 months by Quality Assurance & Performance Improvement committee. Frequency of auditing may be increased at any point by the quality assurance and performance improvement committee based on audit results. Responsible Party: Assistant Director of Nursing for Quality and Education
Emergency Preparedness Plan Lacks Key Provisions
Penalty
Summary
The facility failed to comply with Disaster and Emergency Preparedness requirements as outlined by New York State regulation. Specifically, the facility's emergency preparedness plan did not include provisions for earthquake, flood, or nuclear disaster. This deficiency was identified during a recertification survey, where it was noted that there was no documented evidence of such provisions in the plan. During an interview, the facility's administrator acknowledged the absence of these provisions and indicated an intention to add them.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Disaster Plans developed for Earthquake, Flood and Nuclear events and made part of the Comprehensive Emergency Management Plan. 2. All-Hazard Risk Assessment will be updated to include these required disaster plans; and will be reviewed to identify any other risk which may pose more than a theoretical or nominal risk to ensure plans are developed. 3. Employees will be notified via general information update (email) of the Comprehensive Emergency Management Plan additions, with a copy provided for review. Further education on these plans will be incorporated into annual facility training exercises and disaster drills based on their relative priority as determined by the facility’s risk assessment (previously assessed at ‘low risk’). Families or representatives will be provided an annual overview of the Comprehensive Emergency Management Plan. This information is not detail - plan specific, but a general overview of the facility's emergency response assessment, planning, etc. 4. The development of the respective policies are complete, and have become part of the Comprehensive Emergency Management Plan. Ongoing compliance with this deficiency - which is specifically the absence of these plans - will be reviewed annually as part of annual All Risk Assessment and Comprehensive Emergency Management Plan review. Responsible Party: Administrator
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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