| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0580 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0580 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) not walk. The resident used a wheelchair as his/her main mode of travel. Total care patient. UA due in the morning and CAT scan on Friday. Review of the resident’s nurses’ notes, dated 2/27/19 at 2:00 A.M., showed UA obtained via straight catheter (a thin, sterile tube inserted into the bladder to drain urine from the body). Resident experienced pain and had 500 cc residual, cloudy, purulent, yellow urine with a strong odor. Review of a UA report, dated 2/27/19, showed the following: -Leukocytes (white blood cells) – moderate (normal is negative); -Protein – trace (normal is negative); -Glucose – greater than/equal to 000 (normal 0-0.8 millimoles(mmol)/Liter/L); -Blood – moderate (normal is negative); -White blood cells (WBCs) – too numerous to count (normal is none); -Red blood cells (RBC) – 15-20 (normal is none); -Bacteria – 4+ (normal is none). Review of the resident’s nurse’s notes, dated 2/28/19 at 9:00 A.M., showed the physician was in the facility. New order for Keflex (antibiotic) 500 mg three times daily for five days. Review of the urine culture report, dated 3/1/19, showed the following: -Yeast greater than 100,000 colony forming unit (CFU)/milliliter(ml) after two day incubation. -2/28/19, give 1 gram (gm) [MEDICATION NAME] (antibiotic) IM one time at bedtime. During interview on 4/11/19 at 2:20 P.M., the resident’s physician said the following: -He/she was only in his/her office on Tuesdays and Thursdays; -His/her office (which is closed on Saturday) received a fax, dated 2/23/19, requesting a UA for the resident ASAP; -His/her first opportunity to address the fax would have been 2/26/19, which he/she did and gave the order for the UA; -He/she would have expected staff (who felt the resident needed a UA ASAP) to call him/her as he/she was always available to them; -He/she would not expect staff to fax an ASAP UA request (for a resident with mental status changes) to a closed office. During interview on 4/23/19 at 2:55 P.M., Licensed Practical Nurse (LPN) G said the following: -Staff should not send a fax requesting lab work for a resident ASAP (due to change in condition) to a physician office which is closed; -He/she should have phoned the physician and the order would have been given at that time. During interview on 4/12/19 at 5:05 P.M. and 4/23/19 at 2:00 P.M., the director of nursing said the following: -He/she would not expect nursing staff to send a fax requesting an ASAP UA to a closed physician clinic. He/she expected staff to call and get the order; -He/she would have expected staff to ask the physician for the needed UA on 2/25/19 when staff spoke with the physician regarding the resident’s [MEDICATION NAME]. (Record review showed staff received a telephone order regarding the resident’s [MEDICATION NAME] on 2/25/19.) | |
| F 0623 Level of harm – Potential for minimal harm Residents Affected – Many | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0623 Level of harm – Potential for minimal harm Residents Affected – Many | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for six residents (Residents #40, #39, #9, #41, #33, and #36), in a review of 15 sampled residents and one additional resident (Resident #29) who were transferred to the hospital. The facility census was 43. 1. During interview on 4/11/19 at 4:30 P.M. the Administrator said the facility did not have a policy regarding notification of the Office of the State Long-Term Care Ombudsman of resident discharges and transfers from the facility. 2. Review of Resident #39’s medical record showed the following: -He/She was originally admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the Office of the State Long-Term Care Ombudsman of the resident’s transfers. 3. Review of Resident #33’s medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the Office of the State Long-Term Care Ombudsman of the resident’s transfer. 4. Review of Resident 9’s medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the Office of the State Long-Term Care Ombudsman of the resident’s transfer. 5. Review of Resident #29’s medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the Office of the State Long-Term Care Ombudsman of the resident’s transfer on 4/9/19. 6. Review of Resident #40’s medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the Office of the State Long-Term Care Ombudsman of the resident’s transfer from the facility. 7. Review of Resident #41’s medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the Office of the State Long-Term Care Ombudsman of the resident’s transfer from the facility. 8. Review of Resident #36’s medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the Office of the State Long-Term Care Ombudsman of the resident’s transfer from the facility. 9. During interview on 4/11/19 at 4:25 P.M. the Administrator said the facility only notified the State Ombudsman’s office of 30 day notices issued to residents. The facility did not notify the State Ombudsman’s office of all resident transfers and discharges. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0623 Level of harm – Potential for minimal harm Residents Affected – Many | ||
| F 0625 Level of harm – Potential for minimal harm Residents Affected – Many | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0625 Level of harm – Potential for minimal harm Residents Affected – Many | (continued… from page 4) representative of the facility’s bed hold policy at the time of transfer. 8. Review of Resident #29’s medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an outside facilty for evaluation and treatment of [REDACTED]. -There was no documentation to show the facility notified the resident or his/her legal representative of the facility’s bed hold policy at the time of transfer. 9. During interview on 4/11/19 at 4:00 P.M the Social Services Designee said the following: -He/She reviewed the facility bed hold policy with the resident and his/her legal representative at the time of admission to the facility; -He/She did not provide the resident or his/her legal representative the facility’s bed hold policy at the time of transfer verbally or in writing; -The facility did not have a policy about informing the resident or legal representative in writing at the time of transfer of the facility’s bed hold policy. 10. During interview on 4/11/19 at 4:30 P.M. the Business Office Manager said he/she did not provide the resident or legal representative notification of the facility bed hold policy either verbally or in writing at the time of transfer out of the facility. He/She was unaware the facility should provide the bed hold policy in writing at the time of transfer. 11. During interview on 4/11/19 at 4:25 P.M. the Administrator said the Social Services Designee reviewed the facility bed hold policy with the resident or legal representative at the time of admission. If the bed hold policy was reviewed again at the time of transfer, the Business Office Manager would provide the information. | |
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Assess the resident when there is a significant change in condition **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) Guidelines for determining significant change in resident status included the following: -Any decline in an ADL physical functioning area where a resident is newly coded as 3, 4, or 8; -Resident’s incontinence pattern changes from 0 or 1 to 2, 3, or 4; -Emergence of a pressure ulcer at Stage II or higher, when no pressure ulcers were previously present at Stage II or higher; -Emergence of an unplanned weight loss problem (5% change in 30 days or 10% change in 180 days). 3. Review of Resident#39’s quarterly MDS dated [DATE] showed the following: -The resident’s cognition was moderately impaired; -He/she required extensive assistance of one staff with bed mobility, transfers, walking in and out of his/her room, and locomotion on and off of the unit; -He/she required limited assistance of one staff with personal hygiene. Review of the resident’s quarterly MDS dated [DATE] showed the following: -His/her cognition improved from moderately impaired to intact; -He/she required limited assistance of one staff with bed mobility, transfers, and locomotion on and off of the unit; -He/she required extensive assistance of one staff with personal hygiene; -He/she only ambulated in his/her room once or twice with assist of one staff and did not ambulate out of his/her room. Review of the resident’s quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]: -The resident’s cognition improved from moderately impaired to intact; -The resident improved in bed mobility, transfers and locomotion on and off the unit from extensive assist to limited assist; -The resident declined in personal hygiene from limited assist to extensive assist; -The resident declined in ambulation from extensive assist to only ambulated in his/her room once or twice with assist of one staff and did not ambulation out of his/her room; -The resident’s assessment met the criteria for significant change in status. Review of the resident’s quarterly MDS dated [DATE] showed the following: -His/her cognition declined and now was mildly impaired; -He/she showed a decline in ADLs and now required extensive assistance of two staff with bed mobility and transfers; -Ambulation in his/her room did not occur; -He/she now required extensive assistance of one staff on and off of the unit. Review of the resident’s quarterly MDS dated [DATE] showed the following when compared to the previous quarterly dated 12/16/18 showed the following: -The resident’s cognition declined from intact to moderately impaired; -The resident declined in bed mobility and transfers from limited assist to extensive assist; -The resident declined in ambulation in his/her room from only occurred once or twice with staff assist to did not occur; -The resident’s assessment met the criteria for a significant change in status. Observation of the resident on 4/09/19 at 12:26 P.M showed he/she sat in his/her room with his/her left arm in an immobilizer during lunch. He/she was not eating and said his/her arm hurt too bad to eat. He/she wore oxygen and rubbed his/her left arm. 4. Review of Resident #33’s quarterly MDS dated [DATE] showed the following: -He/She required extensive physical assistance of two staff with transfers; -He/She required limited assistance of one staff with eating; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) -He/She was frequently incontinent of bladder; -He/She was always continent of bowel. Review of the resident’s quarterly MDS dated [DATE] showed the following declines in his/her condition: -He/She was now physically dependent on two staff for all transfers; -He/She was now dependent on one staff to assist with eating; -He/She was now always incontinent of bladder; -He/She was now always incontinent of bowel. The resident’s quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]: -The resident declined in transfers from extensive assist to totally dependent; -The resident declined in eating from limited assist to totally dependent; -The resident declined in continence from frequently incontinent of bladder to always incontinent of bladder and always continent of bowel to always incontinent of bowel; -The resident’s assessment met the criteria for significant change in status. During an interview on 4/12/19 at 12:05 P.M., Certified Nurse Aide (CNA) A said the following: -The resident had declined in transfer status; -The resident used to be a two person stand up transfer and now required the Hoyer lift for transfers since he/she returned from the hospital a few months ago; -Three or four months ago, the resident was able to use the toilet, but now is always incontinent of bowel and bladder; -The resident did not move around and required staff to turn and reposition him/her. 5. Review of Resident #6’s quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Walking in room did not occur; -Required limited assistance of one staff member with locomotion on the unit; -Required limited assistance of one staff member with dressing; -Required set up help with eating; -Not steady, only able to stabilize with staff assistance with moving from seated to standing position and moving on and off the toilet; -Weight 94 pounds. Review of the resident’s quarterly MDS dated [DATE] showed the following: -Moderately impaired cognition; -Walking in room occurred once or twice; -Independent with locomotion on the unit, dressing and eating; -Weight 109 pounds. The resident’s quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]: -The resident improved in cognition from severe to moderately impaired cognition; -The resident improved in walking in room from did not occur to occurred once or twice; -The resident improved in locomotion on the unit and with dressing from required limited assistance of one staff member to independent; – The resident improved in eating from required set up help to independent; -14 percent weight gain in three months; -The resident’s assessment met the criteria for significant change in status. Observation of the resident from 4/9/19 through 4/12/19 showed the resident transferred him/herself to the wheelchair, propelled him/herself down the hallway to the dining room, ate independently, brushed his/her own teeth and hair without staff assistance and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) transferred with staff assistance to the toilet. During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said the resident had improved in status and needed a significant change MDS for improvement. 6. Review of Resident #19’s quarterly MDS dated [DATE] showed the following: -He/She required extensive assistance of two staff with toileting; -He/She was frequently incontinent of bowel and bladder; -He/She weighed 188 pounds. Review of the resident’s quarterly MDS dated [DATE] showed the following: -He/She was totally dependent on two or more staff with toileting; -He/She was always incontinent of bowel and bladder; -His/Her weight was 170 pounds (18 pound weight loss since previous assessment). The resident’s quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]; -The resident declined from extensive assist to totally dependent with toileting; -The resident’s continence declined from frequently incontinent to always incontinent of both bladder and bowel; -10.4% weight loss in three months; -The resident’s assessment met the criteria for significant change. 7. Review of Resident #37’s quarterly MDS dated [DATE] showed the following: -Required extensive assistance of one staff member with bed mobility, dressing, eating, and personal hygiene; -No functional limitation in range of motion of upper and lower extremities. Review of the resident’s quarterly MDS dated [DATE] showed the following: -Required total assistance of two staff members with bed mobility and dressing; -Required total assistance of one staff member with eating and personal hygiene; -Functional limitation in range of motion with impairment of one upper extremity and both lower extremities. The resident’s quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]; -The resident declined from extensive assistance of one staff member to total assistance of two staff members with bed mobility and dressing; -The resident declined from extensive assistance to total assistance of one staff member with eating and personal hygiene; -The resident declined from no functional limitation in range of motion of upper and lower extremities to functional limitation in range of motion with impairment of one upper extremity and both lower extremities; -The resident’s assessment met the criteria for significant change in status. Observation of the resident from 4/9/19 through 4/12/19 showed the resident required two staff members and total assistance with bed mobility, dressing and toileting. The resident was incontinent and wore incontinence briefs. Staff transferred the resident to a wheelchair with a gait belt. The resident was unsteady and had limited weight bearing during the transfer. He/she required one staff member total assistance to propel the wheelchair to the dining room and required total assistance with eating. During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said the resident had declined in status and needed a significant change MDS for decline. 8. During an interview on 4/12/49 at 5:00 P.M., the Director of Nursing said the following: -He/she expected the MDS Coordinator to follow the RAI process and follow the guidelines of when to complete a MDS when a resident has had a significant change in their status; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) -He/she would expect a MDS for a significant change be completed if changes in a resident’s status triggered for one. | |
| F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | PASARR screening for Mental disorders or Intellectual Disabilities **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0645 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) should monitor for drowsiness and dizziness. Review of the resident’s (MONTH) 2019 physician’s orders [REDACTED]. -[MEDICATION NAME] (anti depressant medication) 40 milligrams (mg) daily at 7:00 A.M. for major [MEDICAL CONDITION]; -[MEDICATION NAME] (antipsychotic medication) 25 mg two times daily at 7:00 A.M. and 8:00 P.M. for [MEDICAL CONDITION] disorder. Review of the resident’s medical record showed no PASARR screening (Level I or II). 3. Review of Resident #36’s Admission MDS, dated [DATE] showed the following: -[DIAGNOSES REDACTED]. -Received antipyschotic medications the past seven days; -Received antidepressant medications the past seven days; -Received antipsychotic medications on a routine basis; -No documentation that a PASARR was completed for the resident. Review of the resident’s Significant change MDS, dated [DATE] showed the following: -[DIAGNOSES REDACTED]. -Received antipyschotic medications the the past seven days; -Received antianxiety medications for the past five days; -Received antidepressant medications for the past seven days; -Received antipsychotic medications on a routine basis; -No documentation that a PASARR was completed for the resident. Review of the resident’s care plan dated 3/21/19 showed the following: -Resident admitted on [DATE]; -[DIAGNOSES REDACTED]. -Problem: I take medications which can cause side effects such as drowsiness or dizziness. Monitor me closely after giving me these medications. Review of the Resident’s POS, dated (MONTH) 2019 showed the following: -Amitriptylline 50 mg po daily at 7:00 P.M. for major [MEDICAL CONDITION]; -[MEDICATION NAME] 60 mg po daily at 8:00 P.M. for [MEDICAL CONDITION] disorder; -[MEDICATION NAME] 25 mg po daily at 7:00 A.M. for major [MEDICAL CONDITION]; -[MEDICATION NAME] 0.5 mg po PRN (as needed) two times daily for anxiety disorder. Review of the resident’s medical record showed no PASARR screening. 4.During interview on 4/12/19 at 10:50 A.M. the MDS coordinator said residents admitted with a serious mental illness should have a PASARR completed prior to admission. He/She was responsible for entering the PASARR information into the resident’s MDS. Resident #37 and #36 did not have a PASARR completed as required. During interview on 4/11/19 at 4:25 P.M. the administrator said residents’ PASARR reports should be in the medical record as required. | |
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) drops to treat medical conditions, eye infections and dry eyes. -Staff was to wash and dry hands thoroughly (if treating both eyes, wash and dry before each eye) -Put on gloves; -If the resident is sitting up, tilt his/her head backward slightly; -Gently pull the lower lid down. Instruct the resident to look up. -Drop the medication into the lower eyelid; -Instruct the resident to slowly close his/her eyelid to allow for even distribution of the eye drops; -Instruct the resident not to blink or squeeze the eyelid shut which forces medicine out of the eye; -Remove gloves and discard. Wash and dry hands thoroughly. 2. Review of the [MEDICATION NAME] opthalmic (eye medication used to treat ([MEDICAL CONDITION]) (a group of eye conditions which can cause [MEDICAL CONDITION])) manufacturer’s guidelines, dated 7/18 showed while looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid. Remove your index finger from the eyelid, close your eye for two to three minutes and tip head down as though looking at the floor. Try not to blink or squeeze your eyelids. 3. Review of the [MEDICATION NAME] opthalmic (beta-blocker eye medication used to treat [MEDICAL CONDITION]) manufacturer’s guidelines, dated 11/07 showed gently close the eye after administration of the drop, do not blink. Keep the eyes closed and apply pressure to the inner corner of the eye with your finger for one to two minutes to allow the medicine to be absorbed by the eye. 4. Review of Resident #31’s physicians order sheets (POS) dated 4/19 showed the following: -[DIAGNOSES REDACTED].>-[MEDICATION NAME] 0.2% opthalmic- one drop both eyes two times daily for [MEDICAL CONDITION] (5/25/18); -[MEDICATION NAME] ophthalmic drops 0.5% one drop to both eyes two times daily (5/25/18). Observation on 4/9/19 at 3:45 P.M. in the resident’s room showed the following: -The resident sat in his/her wheelchair; -Certified Medication Technician (CMT) I entered the resident’s room, handed the resident a Kleenex and administered [MEDICATION NAME] one drop into each eye; -CMT I did not instruct the resident to close his/her eyes for two to three minutes or hold pressure to the lacrimal duct. Observation on 4/9/19 at 4:00 P.M. in the resident’s room showed the following: -CMT I entered the resident’s room, handed the resident a Kleenex and administered [MEDICATION NAME] one drop into each eye; -CMT did not instruct the resident to close his/her eyes or hold pressure to the lacrimal duct. 5. Review of Resident #35’s Physician Order Sheet (POS), dated 4/19 showed the following: -[DIAGNOSES REDACTED].>-[MEDICATION NAME] 0.2% eye drops- one drop both eyes three times daily for [MEDICAL CONDITION] (9/14/17); -[MEDICATION NAME] ophthalmic 0.5% apply to both eyes two times daily for open angle [MEDICAL CONDITION] with borderline findings (9/14/17). Observation on 4/9/19 at 3:52 P.M. in the resident’s room showed the following: -The resident lay in bed; -CMT I entered the resident’s room, administered [MEDICATION NAME] one drop into each eye and patted the resident’s eyes momentarily; -CMT I did not instruct the resident to close his/her eyes for two to three minutes or hold pressure to the lacrimal duct. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) Observation on 4/9/19 at 4:05 P.M. in the resident’ room showed the following: -CMT I entered the resident’s room, administered [MEDICATION NAME] one drop into each eye; -CMT I did not instruct the resident to close his/her eyes or hold pressure to the lacrimal duct. During interview on 4/12/19 at 4:25 P.M. CMT I said the following: -He/she had been taught to pull the lower lid of the eye down and administer the drop in the corner and hold pressure for 30 seconds or if the resident was able, instruct them to do so; -He/she forgot to hold pressure after administering the eye drops. During interview on 4/12/19 at 5:05 P.M the Director of Nursing (DON) said he/she would expect staff to hold pressure to the lacrimal duct for at least one minute after a medicated eye drop was given. | |
| F 0689 Level of harm – Actual harm Residents Affected – Few | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 12) -Falls should also be identified as witnessed or unwitnessed events; -For an individual who had fallen, the staff and practitioner would begin to try to identify possible causes within 24 hours of the fall; -If the cause of the fall was unclear, or if a fall may have a significant medial cause, or if the individual continues to fall despite attempted interventions, a physician would review the situation and help further identify causes and contributing factors; -Based on the preceding assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling; -If underlying causes could not be readily identified or corrected, staff would try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation; -The staff would follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma had been ruled out or resolved; -The staff and physician would monitor and document the individual’s response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals were often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences could sometimes be minimized even if falls could not be prevented; -If interventions had been successful in fall prevention, the staff would continue with current approaches and would discuss periodically with the physician whether these measure were still needed; -If the individual continued to fall, the staff and physician would re-evaluate the situation and reconsider possible reasons for the resident’s falling and also reconsider the current interventions; -As needed, after an appropriately thorough review, the physician would document any uncorrectable risk factors and underlying causes. 2. Review of Resident’s #39’s care plan, dated 7/2/18, showed the following: -The resident had a personal history of falls and took medications that could increase fall risk; -He/she would not have any serious injuries due to falls; -Encourage him/her to ask for help with all transfers; -He/she took medications that could cause dizziness and drowsiness which could lead to falls. Monitor him/her after administering these medications; -Keep his/her call light within reach at all times. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 9/25/18, showed the following: -The resident’s cognition was moderately impaired; -He/she required extensive assistance from one staff with bed mobility, transfers, walking in and out of his/her room, and locomotion on and off of the unit and toilet use; -He/she was frequently incontinent of bladder and always continent of bowel; -He/she used a walker and wheelchair; -He/she was not steady and was only able to stabilize with human assistance with changing from seating to standing potion, walking, turning around and facing opposite direction while walking, transferring on and off of the toilet, surface to surface transfers, and transfers between bed to chair or wheelchair; -He/she had one fall with minor injury and one fall with major injury since previous assessment (6/28/18). |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 13) Review of the resident’s fall risk assessment, dated 10/17/18, showed the following: -He/she had one to two falls within the past three months; -He/she was chair-bound; -He/she had problems with balance while standing and walking; -He/she had decreased muscular coordination; -He/she had a change in gait pattern when walking through a doorway; -He/she required the use of an assistive device such as a wheelchair, walker, or cane; -He/she took one or two medications that could cause lethargy (weakness) and confusion; -He/she had one or two predisposing diseases that could cause falls; -His/her total fall risk score was 12, which indicated the resident was at high risk for falls. Review of the resident’s nursing notes, dated 11/18/18 at 3:57 P.M., showed the following: -The resident was observed in the hallway on his/her bottom scooting across the floor; -He/she told staff he/she was trying to transfer himself/herself to the wheelchair from the recliner without wearing shoes; -He/she was encouraged to use his/her call light for assistance and to wear shoes or grip socks during transfers. Review of the resident’s care plan showed a hand written intervention, dated 11/18/18, that instructed staff to educate the resident to ask for assistance when transferring himself/herself. (This intervention was identified on the resident’s care plan prior to the resident’s fall on 11/18/18.) Review of the resident’s nursing notes, dated 11/20/18 at 7:30 P.M., showed the following: -The resident was observed sitting on the floor beside his/her bed; -He/she told staff he/she was getting up from the bed and the bed was not locked and slid out from under him/her. Review of the resident’s care plan showed an intervention was added on 11/20/18 to educate the resident to ask for assistance with transfers to bed so staff can ensure the brakes were locked. (Staff identified the intervention for the resident to ask for assistance with transfers on the resident’s care plan on 7/2/18 and after the resident fell on [DATE].) Review of the resident’s nursing notes, dated 12/15/18 at 1:00 A.M., showed the following: -The resident was observed on the floor in his/her room; -The resident was lying on his/her right side in front of his/her recliner with his/her wheelchair nearby; -He/she was not wearing grip socks;; -The resident told staff he/she was trying to go to the bathroom when his/her feet slid out from under him/her and he/she landed on his/her bottom. Review of the resident’s Post Fall Huddle Guide Form, dated 12/15/18, showed the following: -The resident was at risk for falls; -The resident had not fallen in the past four weeks (documentation showed the resident fell on [DATE]); -The resident had brittle bones; -The resident was going to the bathroom at the time of the fall; -Staff was caring for other residents at the time of the fall; -The resident had not fallen recently, but every fall was basically because the resident was hurting and was weak; -Changes made to the resident’s care plan to decrease the risk of future falls included the resident needed to wear grip socks when self-transferring or have the resident use |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 14) his/her call light and ask for assistance with transfers. (Staff documented in the nurses notes on 11/18/18, they encouraged the resident to wear grip socks after he/she fell while not wearing the socks on 11/18/18.) Review of the resident’s care plan showed an intervention was added on 12/17/18 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident’s care plan on 7/2/18 and after the resident fell on [DATE] and 11/20/18.) Review of the resident’s quarterly MDS, dated [DATE], showed the following: -His/her cognition was intact; -He/she required limited assistance from one staff with transfers and locomotion on and off of the unit; -He/she required extensive assistance of one staff with toileting; -He/she walked in his/her room once or twice with assist from one staff; -He/she did not ambulate out of his/her room; -He/she was frequently incontinent of bladder and always continent of bowel; -He/she used a walker and wheelchair; -He/she was not steady and was only able to stabilize with human assistance with changing from seating to standing potion, walking, turning around and facing opposite direction while walking, transferring on and off of the toilet, surface to surface transfers, and transfers between bed to chair or wheelchair; -He/she had one fall with minor injury and one fall with major injury since previous assessment (6/28/18); -He/she had impairment with one side of his/her lower extremities during range of motion (ROM); -He/she had two non-injury falls and one minor injury fall since previous assessment. Review of the resident’s Care Plan Conference Summary, dated 12/26/18, showed he/she was at high risk for falls due to trying to do things for himself/herself. (There was no evidence staff evaluated or modified current interventions to prevent the resident from falling.) Review of the facility’s fall investigation, dated 1/25/19, showed the resident was found on the floor in front of his/her wheelchair in his/her room on 1/25/19 at 4:50 P.M. The resident stated he/she was transferring himself/herself from the recliner to the wheelchair when he/she slipped and fell on to the floor. Review of the resident’s Post Fall Huddle Guide Form, dated 1/25/19, showed the following: -The resident was transferring himself/herself from the recliner to wheelchair; -Root cause of the fall: the resident did not use his/her call light to ask for assistance; -Changes to the resident’s care plan to decrease the risk of further falls included to remind the resident the importance of using call light to get help while transferring. Review of the resident’s care plan showed an intervention was added on 1/25/19 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident’s care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, and 12/17/18.) Review of the facility’s fall investigation, dated 1/30/19, showed the following: -On 1/30/19 at 11:55 P.M., the resident was getting himself/herself out of bed without wearing socks, slid down the side of the bed, and landed on the floor; -Intervention put into place to prevent further incidents included educating the resident |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 15) of the need for grip socks at all times that shoes were not on. Review of the resident’s Post Fall Huddle Guide Form, dated 1/30/19, showed the following: -The resident was trying to get out of bed without his/her shoes on; -Root cause of the fall: the resident did not use his/her call light to ask for assistance and he/she was not wearing shoes or gripper socks at the time of the incident; -Changes made to the resident’s care plan to decrease the risk of future falls included the resident needed to wear grip socks when self-transferring or have the resident use his/her call light and ask for assistance with transfers; -System problem that needed to be communicated to other departments included to be sure to place non-grip socks on the resident at bedtime. Review of the resident’s care plan showed an intervention was added on 1/30/19 to educate the resident of the need for grip socks at all times that shoes were not on. (Staff documented they provided education to the resident after he/she fell when not wearing grip socks on 11/18/18 and 12/15/18.) Review of the facility’s fall investigation, dated 2/1/19, showed the following: -On 2/1/19 at 3:00 P.M., the resident slipped and fell on to the floor in his/her room while trying to transfer himself/herself from the recliner to the wheelchair; -Intervention put into place to prevent further incidents included to re-educate the resident to use the call light for assistance with transfers. Review of the resident’s Post Fall Huddle Guide Form, dated 2/1/19, showed the following: -He/she was taking himself/herself to the bathroom from the recliner; -Root cause of the fall: the resident slipped when he/she tried to get up; -There were no changes to the resident’s care plan that would decrease the risk for future falls; -The facility was unable to develop interventions to prevent further falls. Review of the resident’s care plan showed an intervention was added on 2/1/19 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident’s care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, and 1/25/19.) Review of the facility’s fall investigation, dated 2/14/19, showed the following: -On 2/14/19 at 1:15 P.M., the resident was found lying on the floor in his/her room. The resident could not remember what had happened; -Intervention to prevent further incident included to educate the resident to use call light when needing to transfer. Review of the resident’s Post Fall Huddle Guide Form, dated 2/14/19, showed the following: -The resident was found lying on the floor on his/her right side and he/she could not tell staff what he/she was doing; -Root cause of the fall: the resident complained of having a headache and nausea with vomiting before lunch. He/she was being treated for [REDACTED]. -The resident had a room at the end of the hall and could not always be heard when he/he asked for help; -Intervention that could be made to decrease risk for future falls included moving the resident closer to the nurse’s station and to check on him/her more frequently; -Remind the resident to use the call light when he/she wanted to get up. Review of the resident’s care plan showed an intervention was added on 2/14/19 to educate the resident to use his/her call light for assistance with transfers. (The interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers were identified on the resident’s care plan on 7/2/18 and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 16) after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, and 2/1/19.) Review of the resident’s nursing notes, dated 2/24/19 at 6:36 P.M., showed the following: -The resident was observed on the floor lying on his/her back between the bed and recliner; -The resident told staff he/she was trying to get up to change into his/her night clothes; -He/she pushed away from his/her sink with brakes not in the locked position; -Re-educated resident on the importance of using call light for assistance and to make sure the brakes were in the locked position if he/she was going to self-transfer. Review of the resident’s Post Fall Huddle Guide Form, dated 2/24/19, showed the following: -There were no changes made to the care plan that could decrease the resident’s risk for future falls; -Interventions that could be made to decrease the risk for future falls or injuries was to move resident to a room that was closer to the nurse’s station; -Due to resident’s frequent fall history, he/she needed to be closer to the nurse’s station; -Fall could have possibly been prevented. Review of the resident’s care plan showed an intervention was added on 2/24/19 to educate the resident to use his/her call light for assistance with transfers and ensuring grip socks were on, and wheelchair brakes were locked. (Staff identified the interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers on the resident’s care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19, and 2/14/19. Staff also provided education to the resident after he/she fell when not wearing grip socks on 11/18/18, 12/15/18, and 1/30/19.) Review of the facility’s fall investigation, dated 2/25/19, showed the following: -On 2/25/19 at 10:20 A.M , the resident was found sitting on the floor in front of his/her recliner; -Intervention to prevent further falls included educating the resident to use call light for assistance when he/she needed to get up. Review of the resident’s Post Fall Huddle Guide Form, dated 2/25/19, showed the following: -The resident was transferring himself/herself; -Root cause of the fall: the resident did not ask for help -Need to consult PT/OT about mobility/positioning/seating (no documentation was found the resident received PT/OT consult); -Changes made to the resident’s care plan to decrease the risk of future falls included reminding the resident to use his/her call light when he/she wanted help. Review of the resident’s care plan showed an intervention was added on 2/25/19 to educate the resident to use his/her call light for assistance with transfers. (Staff identified the interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers on the resident’s care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19, 2/14/19 and 2/24/19.) Review of the resident’s quarterly MDS, dated [DATE], showed the following: -His/her cognition was mildly impaired; -He/she required extensive assistance of two staff with bed mobility, transfers, ambulation, and locomotion off of the unit, and toilet use; -His/her ROM was limited on one side of both upper and lower extremities; -He/she used a walker and wheelchair; -He/she was occasionally incontinent of bladder and always continent of bowel; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 17) -He/she was not steady and was only able to stabilize with human assistance with changing from seating to standing potion, walking, turning around and facing opposite direction while walking, transferring on and off of the toilet, surface to surface transfers, and transfers between bed to chair or wheelchair; -He/she was at risk for falls; -He/she had two non-injury falls and minor injury fall since previous assessment (12/16/18). Review of the facility’s fall investigation report, dated 3/14/19, showed the following: -The resident fell on to the floor on 3/14/19 at 8:25 A.M. when he/she attempted to transfer himself/herself from the wheelchair to the recliner; -The resident complained of left arm pain. Review of the resident’s Post Fall Huddle Guide Form, dated 3/14/19, showed the following: -The resident was transferring himself/herself from his/her wheelchair to the recliner when he/she slipped and fell against the wheelchair; -Staff was feeding residents in the dining room and assisting other residents from the dining room to their rooms at the time the incident occurred; -Root cause of the fall: the resident did not like to ask for assistance and he/she stated he/she was reaching for the call light when he/she fell ; -Changes made to the resident’s care plan to decrease the risk of future falls included moving the resident closer to the nurse’s station; -Interventions that could decrease the risk for future falls or injuries included to encourage the resident to use call light and wait for assistance, and to check on the resident frequently. (Staff identified the interventions to encourage the resident to use his/her call light and to encourage the resident to ask for assistance with transfers on the resident’s care plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19, 2/14/19, 2/24/19, and 2/25/19.) Review of the resident’s care plan showed it was updated on 3/14/19 to show the resident fell and broke his/her humerus (long bone in the upper arm between the elbow and shoulder). Review of the resident’s physician’s progress note, dated 3/15/19 (physician assessed the resident on 3/14/19), showed the following: -The resident complained of left shoulder/upper arm pain; -The resident fell while he/she was trying to transfer himself/herself from the wheelchair to bed; -Examination revealed the resident was holding onto his/her left upper arm; -There was tenderness noted to the proximal humerus; -X-ray of the left shoulder was ordered which was positive for [MEDICAL CONDITION] (situated to the center of the body or the point of attachment) left humerus; -Recommended an appointment with orthopedic physician (physician that specialized in bones); -Limit physical activity and movement of the arm; -Pain management regimen was put into place. Review of the resident’s hospital records, dated 3/15/19, showed the following: -Diagnosis: [REDACTED]. -A shoulder immobilizer was placed on the left shoulder. Review of the resident’s care plan conference summary, dated 3/20/19, showed the following: -The resident was at high risk for falls due to the need for assistance with transfers; -The resident fell very frequently because he/she tried to do things on his/her own |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 18) without asking for help; -He/she fell and broke his/her humerus, but still continued to fall; -He/she was unable to have surgery as he/she was not a candidate for surgery at this time. Review of the resident’s nursing notes, dated 3/28/19 at 5:33 P.M., showed the resident’s physician assessed resident and a new order was received to move the resident closer to the nurse’s station. (Staff noted an intervention to prevent falls for the resident was to move him/her closer to the nurses station after the resident fell on [DATE], 2/24/19, and 3/14/19.) Review of the resident’s nursing note, dated 3/29/19 at 3:44 P.M., showed the resident’s physician was updated of the resident not wanting to move from his/her current room to another room. Review of the resident’s social service progress note, dated 3/29/19, showed the following: -The resident said he/she did not want to move from his/her current room because he/she just got it all set up the way he/she liked it; -The resident said he/she did not like all the noise there was closer to the nurses station and it was much quieter where he/she currently was; -The resident was reassured he/she would receive the same care if he/she moved closer to the nurse’s station. Review of the physician’s response to the social service progress note, dated 4/2/19, showed the following: -When he/she was at the facility on 3/28/19. The resident was crying out in pain from his/her shoulder fracture; -He/she heard the resident calling out in pain because he/she was on the resident’s hallway; -Nursing staff was at the nurse’s station and was unable to hear the resident’s cries; -The resident told him/her at that time and at the previous visits he/she did not use the call light. During an interview on 4/11/19 9:00 AM., the resident said the following: -He/she did not remember anyone asking him/her to move rooms; -It was his/her fault he/she fell because he/she would not call for assistance. Observation on 4/11/19 at 9:00 A.M. showed the resident’s private room was the last room furthest from the nurses station on the south hall. During an interview on 4/11/19 at 10:05 A.M., the resident’s physician said the following: -The resident had fallen multiple times; -The resident’s fall on 3/14/19 resulted in a fractured humerus; -Nursing staff told him/her recommendations were made to move the resident closer to the nurses station but the resident did not want to move; -He/she wrote an order to move the resident closer to the nurse’s station on 3/28/19; -He/she received a faxed response from the facility that stated the resident did not want to move rooms; -He/she responded back to the facility and said he/she was concerned nursing staff could not hear the resident when he/she yelled or cried out. He/she heard the resident calling out in pain because he/she was on that hall close by, but the staff was unable to hear the resident’s cries at the nurse’s station; -The resident told him/her he/she quit using the call light because it did him/her no good. Staff took too long to help him/her and he/she just quit using it; -He/she expected staff to at least encourage the resident to move closer to the nurses station, even if it was only temporarily; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 19) -There was a room available (first room on the right from the nurse’s station on the east hall). During an interview on 4/12/19 at 5:00 P.M., the Director of Nursing (DON) said the following: -The resident used to be in a room closer to the nurse’s station, but wanted to move to a private room. He/she moved when a private room became available; -She and other staff talked to the resident several times about using his/her call light, but the resident was independent; -The resident started to experience falls when he/she would forget to put on grip socks; -Staff has been educated to frequently monitor the resident, which included walking down the hall to check on him/her frequently throughout the day (at least hourly); -The resident fractured his/her left humerus and was sent to the hospital; -The resident fell after he/she was moved away from the nurses station; -The resident refused to move to another room that was closer to the nurse’s station; -Staff, including the DON, the restorative aide and the MDS Coordinator, discussed falls in the IDT meetings; -Care plans were updated during the meetings; -He/she did not know how to prevent the resident from falling. 3. Review of Resident #31’s Fall Risk Assessment, dated 10/28/18, showed the following: -Alert; -History of one to two falls in the past three months; -Chair bound; -Adequate vision; -Unable to perform gait/balance evaluation; -Blood pressure drop less than 20 millimeters of mercury between lying and standing; -Took three to four medications that caused lethargy or confusion; -Had one to two predisposing diseases; -Total fall risk score of 14, indicating the resident was at high risk for falling. Review of the resident’s Care Plan, updated 11/25/18, showed the following: -[DIAGNOSES REDACTED]. -He/she had frequent falls and took medication that could increase his/her fall risk due to side effects. The resident fell while arranging things on his/her bed. Staff should arrange things for the resident to prevent falls. Staff should assist the resident with transfers and dressing. Keep personal items in easy reach, and provide clear pathways. Staff should offer to pull the bed linens down. Remind him/her not to transfer without assistance and keep call light within easy reach. Staff should educate the resident to use the call light. Make sure the wheelchair wheels were locked and grip socks were worn before transferring. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required limited assistance of one staff member with bed mobility and personal hygiene; -Required extensive assistance of one staff member with transfers, dressing and toileting; -Walking in room and in corridor did not occur; -Not steady, but able to stabilize without staff assistance with moving from seated to standing position and while moving on and off the toilet; -Not steady, only able to stabilize with staff assistance during surface-to-surface transfers (transfer between bed and chair or wheelchair); -Impaired functional limitation in range of motion of one upper extremity and both lower extremities; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Actual harm Residents Affected – Few | (continued… from page 20) -Wheelchair mobility device; -Sustained two or more falls with no injury in the previous three months; -Sustained one fall with injury in the previous three months. Review of the resident’s care plan conference summary, dated 12/12/18, showed the resident was at high risk for falls because he/she tried to do thing himself/herself and was too unsteady. Review of the resident’s nurses notes, dated 1/26/19, showed at 1:50 A.M., the resident was found sitting on the bathroom floor in his/her room. The resident stated he/she was transferring himself/herself from the toilet to the wheelchair. While pulling up his/her pants, he/she lost balance and sat down on the floor. Review of the fall investigation, dated 1/26/19, showed the following: -The resident fell in the bathroom to the floor while transferring himself/herself from the toilet to the wheelchair and lost balance while pulling up his/her pant; -Intervention was to educate the resident to use the bathroom call light when needing to transfer. Review of the POS [REDACTED] -Staff knew the resident was at risk for falls and was at high risk for injury from falls related to age and brittle bones; -The resident was transferring himself/herself from the toilet to the wheelchair and trying to pull up his/her pants; -The underlying root cause of the fall was the resident lost his/her balance. Staff was unsure if the resident’s wheelchair was locked; -Staff documented need to consult with physical therapy about mobility, positioning and seating to decrease the risk of additional falls; -Staff documented encourage the resident to use the call light for help with transfers to and from the bathroom as changes to the resident’s care plan to decrease the risk of future falls; -Staff documented to remind the resident frequently to use the call light as interventions to decrease the risk of future falls; -Staff documented the resident was not very steady and was getting more forgetful as system problems to communicate to other departments or disciplines. Review of the resident’s care plan, updated 1/26/19, showed the resident had frequent falls. Staff should educate the resident to use the bathroom call light when needing to transfer. (The intervention for staff to educate the resident on the use of the call light was identified on the resident’s care plan prior to the resident’s fall on 1/26/19.) Review of the resident’s telephone orders, dated 1/30/19, showed an order fo (TR | |
| F 0758 Level of harm – Actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 21) #15 and #19) who exhibited symptoms of potential side effects associated with the use of antipsychotic medications including tongue thrusts, rocking back and forth, tremors and chanting. The facility also failed to ensure three residents (Resident #15, #19, and #40) orders for as needed (PRN) [MEDICAL CONDITION] medications were limited to 14 days as required except if an attending physician believed that it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident’s medical record and indicate the duration for the as needed order. The facility census was 43. 1. Review of the facility policy Tapering Medications and Gradual Drug Dose Reduction dated (MONTH) 2007 showed the following: -After medications were ordered for a resident, the staff and practitioner should seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; -All medications should be considered for possible tapering. Tapering that was applicable to antipsychotic medications should be referred to as gradual dose reduction; -Resident who use antipsychotic drugs should receive gradual dose reductions and behavioral interventions, unless clinically contraindicated in an effort to discontinue these drugs; -Periodically, the staff and practitioner would review the continued relevance of each resident’s medications; -The attending physician and staff would identify target symptoms for which a resident was receiving various medications. The staff would monitor for improvement in those target symptoms and provide the physician with that information; -The staff and practitioner would consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication was benefiting the resident; -The staff and practitioner would consider tapering under certain circumstances including when the resident’s clinical condition had improved or stabilized, the underlying causes of the original target symptoms had resolved, non-pharmacological interventions including behavioral interventions had been effective in reducing symptoms or a resident’s condition had not responded to treatment or had declined despite treatment; -The physician would review periodically whether current medications were still necessary in their current doses; -The physician would order appropriate tapering of medications as indicated; -When a medication was tapered or stopped the staff would closely monitor the resident and would inform the physician if there was a return or worsening of symptoms; -When a medication was tapered or stopped the staff and practitioner would document the rationale for any decisions to restart a medication or reverse a dose reduction; -Resident who use antipsychotic drugs should receive gradual dose reductions unless clinically contraindicated in an effort to discontinue the use of such drugs. Pertinent behavioral interventions would also be attempted; -Within the first year after a resident was admitted on an antipsychotic medication or after the resident was started on an antipsychotic medication the staff and practitioner should attempt a GDR in two separate quarters (with at least one month between the attempts) unless clinically contraindicated. After the first year, the facility should attempt a GDR at least annually, unless clinically contraindicated; -For any individual who was receiving an antipsychotic medication to treat behavioral symptoms related to dementia, the GDR may be considered clinically contraindicated if the resident’s target symptoms returned or worsened after the most recent attempt at a GDR |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 22) within the facility and the physician had documented the clinical rationale for why any additional attempted dose reduction at the time would be likely to impair the resident’s function or increase distressed behavior; -For any individual who was receiving an antipsychotic medication to treat a psychiatric disorder other than behavioral symptoms related dementia (for example, [MEDICAL CONDITION] bi-polar mania, or depression with psychotic features), the GDR may be considered contraindicated if the continued use was in accordance with relevant current standards of practice and the physician had documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying psychiatric disorder or the resident’s target symptoms returned or worsened after either most recent attempt at a GDR within the facility and the physician had documented the clinical rational for why any additional attempted dose reduction at the time would be likely to impair the residents function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; -Attempted tapering of sedatives and hypnotics should be considered as a way to demonstrate whether the resident was benefiting from the medication or might benefit from a lower or less frequent dose. Tapering should be done consistent with the following: For as long as a resident remained on a sedative/hypnotic that was used routinely and beyond the manufacturer’s recommendations for duration of use, the physician should attempt to taper the medication at least quarterly unless clinically contraindicated. Clinically contraindicated means the continued use was in accordance with relevant current standards of practice and the physician had documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying psychiatric disorder or the resident’s target symptoms returned or worsened after either most recent attempt at a GDR within the facility and the physician had documented the clinical rationale for why any additional attempted dose reduction at the time would be likely to impair the residents function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. 2. Review of www.drugs.com showed the following: -[MEDICATION NAME][MEDICATION NAME]([MEDICATION NAME]) is an antipsychotic medication. It works by changing the effects of chemicals in the brain. It is a long-acting injection used to treat [MEDICAL CONDITION] and symptoms of [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]). Check with your physician immediately if any of the following side effects occur while taking [MEDICATION NAME]: trembling and shaking of the fingers and hands, lip smacking or puckering, restlessness or need to keep moving (severe). Oral [MEDICATION NAME]: The most commonly reported side effects included sedation, increased appetite, extrapyramidal symptoms, and parkinsonism (a neurological disorder resembling [MEDICAL CONDITION](a disorder of the central nervous system that affects movement, often including tremors)); -[MEDICATION NAME] ([MEDICATION NAME]) belongs to a group of drugs called benzodiazepines. [MEDICATION NAME] affects chemicals in the brain that may be unbalanced in people with anxiety. The sedative effects of [MEDICATION NAME] may last longer in older adults. Accidental falls are common in elderly patients who take benzodiazepines. [MEDICATION NAME] should be used for only a short time; -[MEDICATION NAME] (aripiprazole) is an antipsychotic medication. It works by changing the actions of chemicals in the brain. [MEDICATION NAME] is not approved for use in psychotic conditions related to dementia. [MEDICATION NAME] may increase the risk of death in older |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 23) adults with dementia-related conditions. 3. Review of Resident #19’s physician’s orders sheet (POS), dated 6/1/18 to 6/30/18, showed the following: -The resident’s [DIAGNOSES REDACTED]. -On 6/1/18, [MEDICATION NAME] (antipsychotic medication) 25 milligrams (mg) three times a day (TID); -On 6/18/18, [MEDICATION NAME] was discontinued and [MEDICATION NAME][MEDICATION NAME] mg was ordered to be administered every two weeks. Review of the resident’s psychiatric evaluation, dated 7/6/18, showed the following: -The resident received [MEDICATION NAME] 25 mg intramuscularly (IM) every two weeks; -The resident was oriented to person; -The resident denied any suicidal or homicidal ideation; -The resident’s mood was okay and his/her insight and judgement were limited; -Assessment revealed impulse control disorder (psychiatric disorder characterized by impulsivity/failure to resist temptation, an urge, or the inability to not speak on a thought); -The resident had a history of [REDACTED].>-Plan was to admit him/her to the senior behavioral health department and provide good care environment and medication management. Review of the resident’s psychiatric evaluation, dated 7/7/18, showed the following: -The resident was referred to behavioral health for being agitated and trying to hit people; -He/she had worsening of his/her cognitive impairment and memory; -He/she was very irritable, had increased confusion and was unable to be redirected; -The resident’s psychiatric history included a history of dementia. Review of the resident’s Level One Facility Pre-Admission Screening for Mental Illness/Mental [MEDICAL CONDITION] of Related Condition (PASRR), dated 7/13/18, showed the following: -The resident was argumentative and he/she hit staff, yelled, and had hallucinations and delusions; -The resident was not diagnosed with [REDACTED]. -Primary reason for nursing home placement was [MEDICAL CONDITION] and dementia with behavioral disturbances. Review of the resident’s undated [MEDICAL CONDITION] Disorder Diagnostic Tool, undated, provided by the facility, showed the following: -The resident was delusional; -The resident had hallucinations; -The resident had grossly disorganized behaviors; -The resident had negative symptoms such as affective flattening (a person’s face appeared immobile and unresponsive, there was poor eye contact and reduced body language), alogia (characterized by brief, laconic, empty replies. Decreased fluency and productivity of speech which may arise from diminution of thoughts), and avolition (characterized by an inability to initiate and persist in goal directed activities). Review of the resident’s Medication Administration Record [REDACTED] -[MEDICATION NAME][MEDICATION NAME] mg/2 ml administer 2 ml IM every two weeks. Staff documented medication administered on 7/3/18; -Resident had an order for [REDACTED].M.; -Resident had an order for [REDACTED]., 7:00 A.M., 11:00 A.M., 3:00 P.M., 7:00 P.M., and 11:00 P.M. Staff documented the resident received [MEDICATION NAME] 1 mg tablet as ordered on [DATE] to 7/4/19; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 24) -He/she did not receive [MEDICATION NAME] 1 mg tablet on 7/5/18 at 3:00 P.M., 7:00 P.M., or 11:00 P.M. (Staff did not document why the resident did not received the medication.) Record review showed the resident was transferred to an outside behavioral health facility on 7/6/18 and readmitted to the facility on [DATE]. Review of the resident’s POS, dated (MONTH) (YEAR), showed the following: -On 8/1/18, the resident was readmitted with orders for [MEDICATION NAME] (antidepressant) 50 mg at bedtime (HS), and [MEDICATION NAME] 0.25 mg twice daily (BID), [MEDICATION NAME] 2 mg/ml; administer 1 ml injection IM every four hours PRN (as previously ordered on [DATE]), and [MEDICATION NAME][MEDICATION NAME] mg/2 ml administer 2 ml IM every 2 weeks (as previously ordered on [DATE]); -On 8/3/18, orders were obtained to administer [MEDICATION NAME] 0.25 mg BID for four days then discontinue and if needed, increase [MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks. Review of the resident’s significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be complete by facility staff, dated 8/8/18, showed the following: -His/her cognition was moderately impaired for making daily decisions; -He/she had behaviors such as physical aggression and verbal aggression toward others for one to three days during the look back period; -Behaviors interfered with the resident’s care and social interaction; -The resident required extensive assistance from two staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -He/she did not walk; -He/she had limited range of motion (ROM) with one side of both upper and lower extremities; -He/she was frequently incontinent of bowel and bladder; -He/she weighed 193 pounds; -He/she received antipsychotic medications for the previous seven days; -He/she received antipsychotic medications on a routine basis; -A gradual dose reduction (GDR) was not attempted and/or documented as contraindicated by the physician. Review of the resident’s care plan, dated 8/10/18, showed the following: -He/she had been having inappropriate behaviors; -He/she had a new order for [MEDICATION NAME] to be administered IM every two weeks and the dose could be increased if his/her behaviors continued; -He/she had struck another resident and would take his/her fist and swing into the air; -Staff was to tell him/her this was not appropriate and could not be tolerated; -He/she yelled at other residents and staff; -Staff was to provide a calm quiet environment when he/she became agitated; -He/she was paralyzed on his/her left side; -He/she had a stroke and his/her speech was slurred and he/she was hard of hearing; -He/she also had times of [MEDICAL CONDITION]; -Staff was to try to redirect him/her when he/she was in a [MEDICAL CONDITION] state and assist him/her from becoming upset. Review of the resident’ POS, dated 8/1/18 to 8/30/18, showed on 8/24/18 [MEDICATION NAME][MEDICATION NAME] increased to 50 mg IM every two weeks. Review of the resident’s medical record showed no documentation to support the reason for increasing the [MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks. Review of the resident’s POS, dated 9/1/18 to 9/30/18, showed the following: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 25) -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (original order dated 8/1/18 and was open ended). Review of the resident’s MAR, dated 9/1/18 to 9/30/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME] 1 ml PRN on 9/9/18 and 9/13/18; -Staff administered [MEDICATION NAME][MEDICATION NAME] mg IM on 9/12/18. No documentation the medication was administered on 9/26/18. Review of the resident’s POS, dated 10/1/18 to 10/31/18, showed the following: -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (order was started on 8/1/18 and was open ended). Review of the resident’s MAR, dated 10/1/18 to 10/31/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME] 1 ml PRN on 10/12/18; -The resident received [MEDICATION NAME][MEDICATION NAME] mg IM on 10/10/18 and 10/23/18. Review of the resident’s medical record showed no evidence a gradual dose reduction of the resident’s antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) (YEAR) or documentation to show a GDR would have been contraindicated. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -His/her cognition was moderately impaired for daily decision making; -He/she had no behaviors; -He/she required extensive assistance from one staff with bed mobility and personal hygiene; -He/she required extensive assistance from two staff with transfers and toileting; -His/her ROM was limited on one side of both upper and lower extremities; -He/she was frequently incontinent of bowel and bladder; -He/she weighed 188 pounds (five pounds loss since previous assessment on 8/8/18); -He/she received antipsychotic medications one day during the seven day look back period; -The resident received antidepressants and antianxiety medications seven times during the previous seven day look back period; -There was no GDR attempted and/or documented as contraindicated by the resident’s physician. Review of the resident’s POS, dated 11/1/18 to 11/30/18, showed the following orders: -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (order was started on 8/1/18 and was open ended). Review of the resident’s MAR, dated 11/1/18 to 11/30/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME][MEDICATION NAME] mg IM on 11/6/18, 11/14/18, and 11/20/18; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 11/13/18, showed the pharmacist reviewed the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 26) resident’s medications and did not address the resident’s antipsychotic and [MEDICAL CONDITION] medications. Review of the resident’s medical record showed no evidence a gradual dose reduction of the resident’s antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) (YEAR), and no documentation to show a GDR would have been contraindicated. Review of the resident’s POS, dated 12/1/18 to 12/31/18, showed the following: -[MEDICATION NAME] 50 mg at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] 50 mg IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; 1 ml every four hours PRN for anxiety/aggression (order was started on 8/1/18 and was open ended). Review of the resident’s MAR, dated 12/1/18 to 12/31/18, showed the following: -The resident received [MEDICATION NAME] 50 mg at HS daily; -The resident received [MEDICATION NAME][MEDICATION NAME] mg IM on 12/4/18 and 12/18/18; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 12/11/18, showed the pharmacist reviewed the resident’s medications and did not address the resident’s antipsychotic and [MEDICAL CONDITION] medications. Review of the resident’s medical record showed no evidence a gradual dose reduction of the resident’s antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) (YEAR), and no documentation to show a GDR would have been contraindicated. Review of the resident’s POS, dated 1/1/19 to 1/31/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 ml every four hour IM PRN (original order dated 8/1/18 and was open ended). Review of the resident’s MAR, dated 1/1/19 to 1/31/19, showed the resident received [MEDICATION NAME] 50 mg at HS daily. Review of the resident’s treatment administration record (TAR), dated 1/1/19 to 1/31/19, showed the following: -Staff administered [MEDICATION NAME][MEDICATION NAME] mg/2 ml to the resident on 1/1/19, 1/15/19, and 1/29/19; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 1/8/19, showed the pharmacist reviewed the resident’s medications and did not address the resident’s antipsychotic and [MEDICAL CONDITION] medications. Review of the resident’s medical record showed no evidence a gradual dose reduction of the resident’s antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) 2019, and no documentation to show a GDR would have been contraindicated. Review of the resident’s quarterly MDS, dated [DATE], showed the following: -His/her cognition was moderately impaired for daily decision making; -He/she had no behaviors; -He/she required assistance of one staff with bed mobility, locomotion off of the unit, and personal hygiene; -He/she was dependent on staff for toilet use; -His/her ROM was limited on one side of both upper and lower extremities; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 27) -He/she was incontinent of bowel and bladder; -He/she weighed 170 pounds (18 pound weight loss since previous assessment on 11/8/18); -He/she did not receive antipsychotic medications one day during the seven day look back period; -He/she received antidepressant medications six times during the previous seven day look back period; -He/she did not receive antianxiety medications; -There was no GDR attempted and/or documented as contraindicated by the resident’s physician. Review of the resident’s POS, dated 2/1/19 to 2/28/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 ml every four hour (IM) PRN (original order dated 8/1/18 and was open ended). Review of the resident’s MAR, dated 2/1/19 to 2/28/19, showed the resident received [MEDICATION NAME] 50 mg at HS daily. Review of the resident’s TAR, dated 2/1/19 to 2/28/19, showed the following: -The resident received [MEDICATION NAME][MEDICATION NAME] mg/ml on 2/12/19 and 2/26/19. -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 2/12/19, showed the pharmacist reviewed the resident’s medications and did not address the resident’s antipsychotic and [MEDICAL CONDITION] medications. Review of the resident’s medical record showed no evidence a gradual dose reduction of the resident’s antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) 2019, and no documentation to show a GDR would have been contraindicated. Review of the resident’s POS, dated 3/1/19 to 3//31/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 mg/ml every four hour (IM) PRN (original order dated 8/1/18 and was open ended). Review of the resident’s MAR, dated 3/1/19 to 3/31/19, showed the resident received [MEDICATION NAME] 50 at HS daily. Review of the resident’s TAR, dated 3/1/19 to 3/31/19, showed the following: -Staff documented the resident received [MEDICATION NAME][MEDICATION NAME] mg/2 ml on 3/12/19 and 3/25/19; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Review of the pharmacist review, dated 3/18/19, showed the pharmacist reviewed the resident’s medications and did not address the resident’s antipsychotic and [MEDICAL CONDITION] medications. Review of the resident’s medical record showed no evidence a gradual dose reduction of the resident’s antipsychotic and [MEDICAL CONDITION] medications was attempted in (MONTH) 2019, and no documentation to show a GDR would have been contraindicated. Review of the resident’s POS, dated 4/1/19 to 4/30/19, showed the following: -[MEDICATION NAME] 50 mg PO at HS (original order dated 8/1/18); -[MEDICATION NAME][MEDICATION NAME] mg/2 ml; administer 2 ml IM every two weeks (original |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 28) order dated 8/24/18); -[MEDICATION NAME] 2 mg/ml; administer 1 mg/ml every four hour (IM) PRN (original order dated 8/1/18 and was open ended). Review of the resident’s MAR, dated 4/1/19 to 4/30/19, showed the resident received [MEDICATION NAME] 50 mg at HSdaily. Review of the resident’s TAR, dated 4/1/19 to 4/30/19, showed the following: -The resident received [MEDICATION NAME][MEDICATION NAME] mg/2 ml IM on 4/9/19; -No evidence the resident received PRN [MEDICATION NAME] 2 mg/ml; 1 ml every four hours for anxiety/aggression. Observation on 4/09/19 at 11:16 A.M. showed the resident sat in his/her wheelchair. The resident was thrusting his/her tongue and had a tremor in his/her right arm and hand. Observation on 4/10/19 at 6:11 A.M. showed the resident lay in bed. The resident had a tremor in his/her right arm and the resident was repeatedly chanting. The resident’s speech was unclear. Observation on 4/12/19 at 8:30 A.M. showed the resident had a tremor in his/her right hand. Review of the resident’s medical record showed there was no documentation of the resident’s face/mouth movements or tremors. During an interview on 4/12/19 at 10:20 A.M., Certified Nursing Assistant (CNA) B said he/she noticed the resident’s tremor and mouth and tongue movement since he/she started at the facility in (MONTH) (YEAR). During an interview on 4/12/19 at 9:15 A.M., Certified Medication Technician (CMT) D said the following: -He/she was familiar with the resident; -Potential side effects of antipsychotic medications included behaviors the opposite of what was being treated, increased anxiety, decreased appetite, and decreased alertness; -The resident had not always had thrusting of his/her tongue and tremors, and had just developed those symptoms within the last six months. During an interview on 4/19/19 at 1:16 P.M., Licensed Practical Nurse (LPN) C said the following: -He/she was not aware of any assessment that assessed residents for involuntary movements at the facility; -He/she was familiar with these assessments, but they were not conducted at the facility. During an interview on 4/12/19 at 10:45 A.M., Registered Nurse (RN) C said the following: -Tardive dyskinesia (neurological disorder characterized by involuntary movements of the face and jaw) was a side effect of antipsychotic medications; -He/she thought the resident showed signs of tardive dyskinesia which started within the past two or three months; -The resident received injections (antipsychotic medication) every two weeks; -He/she thought the resident’s tremor started approximately six or seven months ago ([MEDICATION NAME][MEDICATION NAME] increased on 8/24/18 and no GDR had been attempted); -Non-pharmacological approaches to try with the resident would include talking with him/her and reorienting him/her, but he/she did not think the resident had the mental capacity to understand. During an interview on 4/19/19 at 1:12 P.M., the MDS Coordinator said the following: -He/she was not aware of any kind of assessment that assessed involuntary movements; -He/she went by the nurse’s assessment when completing MDSs, but would conduct his/her own assessment if he/she did not agree with other nurse’s assessment; -He/she said the resident came to the facility after he/she had a stroke, but was unsure |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 29) of the resident’s symptoms of tardive dyskinesia and tremor. During an interview on 4/12/19 at 5:00 P.M., the Director of Nursing (DON) said the following: -Side effects of antipsychotic medications included tardive dyskinesia and shaking of the hands (tremors); -The resident had been on antipsychotic medications for over a year; -He/she thought the resident had shaking of his/her hand and symptoms of tardive dyskinesia prior to his/her admission to the facility; -He/she didn’t believe a GDR had been attempted for the resident’s [MEDICATION NAME]; -He/she expected staff to monitor for side effects that could be potentially caused by medication, and notify the physician when they were noticed; -There was no system for monitoring antipsychotic medication use; -Pharmacy recommendations were left on an envelope at the desk with the physician’s name on it so he/she could review them and either accept or decline the pharmacist’s recommendations; -He/she was not aware of the regulation regarding [MEDICATION NAME] PRN orders only being good for 14 days then the resident must be physically re-assessed for continued use; -He/she would expect nursing staff to remind the physician for the PRN [MEDICATION NAME] renewal when it was time (14 days after ordered); -He/she was not aware the pharmacist was not conducting the GDR recommendations like he/she was supposed to; -The current pharmacist had been there for the past year. During an interview on 4/18/19 at 3:10 P.M, the Administrator said the following: -He/she was unaware of any GDR attempts for the resident; -The resident’s [MEDICATION NAME] dose had been increased not decreased at any time. During an interview on 4/12/19 at 2:15 P.M., the resident’s physician said the following: -A side effect of antipsychotic medication use would include tardive dyskinesia and tremors; -He/she did not notice the resident’s symptoms of tardive dyskinesia and tremors all of the time, but did once in a while; -He/she expected staff to assess and report any signs and symptoms of any potentially medication related side effects, such as tardive dyskinesia and tremors; -He/she was unable to recall if the resident’s GDR had been individually assessed. 4. Review of Resident #15’s psychiatric in-patient progress note, dated 10/24/18, showed the following: -He/she was admitted to the psychiatric unit because of increased confusion, aggression, and sexually inappropriate behaviors; -His/her medications included [MEDICATION NAME] ([MEDICATION NAME]) 0.125 mg BID; -Impression: Alzheimer’s dementia late onset and impulse control disorder; -Plan: encouraged the use of environmental modifications and non-pharmacological approaches of management of behavioral and psychological symptoms and to monitor for medications side effects. Review of the resident’s admission MDS, dated [DATE], showed the following: -The resident was admitted to the facility on [DATE]; -The resident’s cognition was intact; -The resident had no behaviors or [MEDICAL CONDITION]; -The resident was independent with activities of daily living (ADLs); -The resident was continent of bowel and bladder; -The resident received antipsychotic medications seven days out of the previous seven-day |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Actual harm Residents Affected – Few | (continued… from page 30) look back period. Review of the resident’s POS, dated 10/26/18 to 10/31/18, showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (antipsychotic medication) 2 mg at bedtime (HS); -[MEDICATION NAME] (sedative; antianxiety medication) 1 mg BID PRN for increased anxiety (order was open ended with no stop date); -[MEDICATION NAME] 0.125 mg BID for delusions and behavioral disturbances. Review of the resident’s MAR, dated 10/26/18 to 10/31/18, showed the following: -The resident received [MEDICATION NAME] 1 mg PRN for increased anxiety on 10/26/18 and 10/27/18; -The resident received [MEDICATION NAME] 2 mg at HS daily; -The resident received [MEDICATION NAME] 0.125 mg BID for delusions and behavioral disturbances daily. Review of the resident’s care plan, dated 11/7/18, showed the following: -The resident took medications that could cause side effects that could increase fall risk; -Monitor him/her after administering antidepressants and antianxiety medications for signs of drowsiness or dizziness; -The resident had [DIAGNOSES REDACTED]. -The resident loved to talk about keeping bee hives and the things bees did; -There was no evidence to show why the resident | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) -The resident had a [DIAGNOSES REDACTED]. -The resident had an order dated 8/16/18 for [MEDICATION NAME] 0.6 milligram (mg) per one milliliter (ml); administer 1.8 mg subcutaneous (SQ, under the skin) after breakfast every morning at 8:30 A.M. Observation of the facility’s medication storage room on 4/12/19 at 4:21 P.M. showed a used [MEDICATION NAME]pen labeled for the resident that was was opened, undated, and had an order date of 3/24/19. Review of the resident’s Medication Administration Record [REDACTED].M. as ordered from 4/1/19 to 4/12/19. 4 Review of Resident #23’s POS dated 4/1/19 to 4/30/19 showed the following: -The resident had a [DIAGNOSES REDACTED]. -The resident had an order dated 2/28/19 for [MEDICATION NAME] U-100 100 unit/ ml., administer 10 units SQ every morning at 7:00 A.M. Review of the resident’s Medication Administration Record [REDACTED].M. from 4/1/19 to 4/12/19. Observation of the facility’s medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of [MEDICATION NAME] that was labeled for the resident with an order date of 1/23/19 and medication missing from the vial. 5. Review of Resident #40’s POS dated 4/1/19 to 4/30/19 showed the following: -The resident had a [DIAGNOSES REDACTED]. -The resident had an order dated 3/20/19 for [MEDICATION NAME] 30 units SQ every morning at 7:00 A.M. Review of the resident’s MAR indicated [REDACTED].M. from 4/1/19 to 4/12/19. Observation of the facility’s medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of [MEDICATION NAME] that was labeled for the resident with an order date of 3/14/19 and medication missing from the vial. 6. Review of Resident #37’s POS dated 4/1/19 to 4/30/19 showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] (Humalog) insulin 100 unit/ml ordered on [DATE] administer per sliding scale four times daily before meals and at bedtime. If blood sugar was 150-199, give one unit. If blood sugar was 200-249, give two units. If blood sugar was 250-299, give three units. If blood sugar was 300-349, give four units. If blood sugar was 350 or above give five units and notify the physician; -On 4/2/19 the sliding scale Humalog insulin 100 unit/ml order was changed. If blood sugar was 150-199, give two units. If blood sugar was 200-249, give four units. If blood sugar was 250-299, give six units. If blood sugar was 300-349, give eight units. If blood sugar was 350 or above notify the physician. Review of the resident’s MAR indicated [REDACTED]. Observation of the facility’s medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of Humalog Insulin that was labeled for the resident with an order date of 3/19/19 and medication missing from the vial. 7. Review of Resident #143’s POS dated 4/1/19 to 4/30/19 showed the following: -The resident had a [DIAGNOSES REDACTED]. -The resident had an order dated 4/5/19 for [MEDICATION NAME] 100 unit/ml, administer 25 units SQ every day at bedtime; -[MEDICATION NAME] order was changed on 4/6/19 to 28 units SQ every day at bedtime. Review of the resident’s MAR indicated [REDACTED] -The resident received [MEDICATION NAME] 100 unit/ml; administer 25 units SQ every day at bedtime daily on 4/5/19 and 4/6/19; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) -Staff documented that the resident received [MEDICATION NAME] 28 units SQ every day at bedtime from 4/6/19 to 4/11/19. Observation of the facility’s medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of [MEDICATION NAME] that was labeled for the resident with an order date of 4/6/19 and medication missing from the vial. During an interview on 4/12/19 at 4:25 P.M., Licensed Practical Nurse (LPN) A said the following: -Nurses were supposed to label insulin when opened because insulin was only good for 28 days after it had been opened; -He/She did not know why the insulins were not labeled; -He/She would assume the insulin was opened on the order date, but they should be replaced if not dated because he/she did not know for sure when they were opened. -He/She would hope that insulin with a start date of 1/23/19 was not still in use because that would be past the 28 days. During an interview on 4/12/19 at 5:00 P.M., the Director of Nursing (DON) said that insulin should be dated and timed when the vials and/or syringes were opened. Staff should not use insulins if they were not labeled. Insulins were good for 28 days after they were opened. He/she expected staff to discard the insulin and reorder it if it was not dated. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 33) through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and /or posted throughout the facility; -Wash hands with soap and water when hands were visible soiled; -Use an alcohol-based hand rub or soap and water before and after direct contact with resident and before and after handling an invasive device (medical equipment). -Use an alcohol-based hand rub or soap and water before preparing or handling medications, before donning gloves, before handling clean or soiled dressings and before moving from a contaminated body site to a clean body site during resident care; -Use an alcohol-based hand rub or soap and water after contact with a resident’s skin, after contact with blood or bodily fluids, after handling used dressings and contaminated equipment, after contact with objects (medical equipment) in the vicinity of the resident, and after removing gloves; -The use of gloves did not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections; -Single-use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids. 3. Review of the facility policy Personal Protective Equipment, Using Gloves dated (MONTH) 2010 showed the following: -Use gloves when touching excretions secretions, blood, body fluids, mucous membranes or non-intact skin; -Use gloves when cleaning up spills or splashes of blood or body fluids; -Wash hands after removing gloves (gloves do not replace hand washing) 4. Review of the facility policy, Instillation of Eye Drops, last revised 1/14 showed the following: The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. -Staff was to wash and dry hands thoroughly (if treating both eyes, wash and dry before each eye) -Put on gloves; -If the resident is sitting up, tilt his/her head backward slightly; -Gently pull the lower lid down. Instruct the resident to look up. -Drop the medication into the lower eyelid; -Instruct the resident to slowly close his/her eyelid to allow for even distribution of the eye drops; -Instruct the resident not to blink or squeeze the eyelid shut which forces medicine out of the eye; -Remove gloves and discard. Wash and dry hands thoroughly. 5. Review of Resident #40’s Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility and dated 3/21/19 showed the following: -Total dependence of two staff for bed mobility; -Presence of stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister); -Presence of urinary catheter (a thin, sterile tube inserted into the bladder to drain urine from the body). Review of the resident’s Physician Order Sheet (POS) dated 4/19 showed the following: -Coccyx (tailbone) wound: cleanse with wound cleanser. Apply hydrogel (provides a moist wound-healing environment and helps remove dead tissue from the wound bed) to necrotic |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 34) (dead tissue), area only with dry dressing every two days or when soiled (3/25/19); -[MEDICATION NAME] moisture powder (powder to reduce moisture) to reddened areas two times daily and PRN; -Urinary catheter, change monthly and PRN (as needed) 3/14/19. Observation on 4/11/19 at 10:00 A.M. showed the following: -The resident lay in his/her bed; -Licensed Practical Nurse (LPN) E and Certified Nurse Aide (CNA) B stood at the bedside, gloved and preparing to provide cares; -CNA B performed perineal care and without changing gloves or washing hands, opened an alcohol prep pad and wiped the urinary catheter from the insertion site outward using the same area of the pad times two swipes. He/she then dropped the pad between the resident’s legs, picked it up and again, wiped from the insertion site downward; -CNA B, without changing gloves and washing hands, rolled the resident to his/her right side and as LPN E held the resident over, wiped the resident’s backside; -CNA B, wearing the same, soiled gloves, and LPN E rolled the resident to his/her back and pulled him/her up in bed; -LPN E assisted the resident to roll to his/her left side. There was no dressing to the resident’s coccyx. He/She cleansed the wound with wound cleanser and gauze and placed the soiled gauze directly on the bed linens. While wearing the same soiled gloves, he/she applied hydrogel to the wound, pulled his/her pen out of his/her pocket, dated the dressing and applied it over the resident’s wound. He/She then applied [MEDICATION NAME] powder to the resident’s reddened groin, peri-area; -LPN E and CNA B, wearing the same soiled gloves, repositioned the resident, picked up and applied the resident’s moon boots and placed a wedge behind the resident’s back; -LPN E picked up the soiled gauze from the bed and while holding the gauze in in his/her soiled gloved hands pulled the sheet over the resident. During interview on 4/12/19 at 4:20 P.M CNA B said the following: -He/She had been trained to use an alcohol wipe for catheter care; -He/She had been taught to only make one swipe and then fold cloth or get new wipe; -He/She should have used a new alcohol pad for each swipe when performing catheter care; -Gloves should be removed and hands washed after perineal care and new gloves applied before performing catheter care; -Clean items should not be touched with soiled hands. During interview on 4/23/19 at 8:35 P.M , LPN E said the following: -After removing a soiled dressing, gloves should be removed and hands washed before regloving and applying the new one; -Hands should be washed or sanitized with hand gel between glove changes; -Clean items/surfaces should not be touched with soiled hands; -Soiled wound dressing supplies should be placed in the trash can and not on the resident’s bed linens. 6. Review of Resident #41’s POS, dated 4/19 showed the resident had a malignant neoplasm (malignant growth or tumor) of rectum. Review of the Resident’s care plan dated 3/14/19 showed the following: -Problem: I have an [MEDICAL CONDITION] (connection of the small intestine to the abdominal wall) and need assistance with emptying it and keeping it clean; -Approach: Assist me with cares and keep the skin around the [MEDICAL CONDITION] clean and monitor for any skin breakdown. Observation on 04/10/19 at 5:05 A.M. showed the following: -LPN H entered the room where the resident lay on his/her back in the bed; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 35) -Without washing his/her hands, LPN H applied gloves, laid a pre-cut stoma (artificial opening in the abdominal wall to allow feces to pass through) wafer and [MEDICAL CONDITION] bag on the arm of the resident’s recliner. He/she removed the soiled wafer from the resident’s abdomen, threw it in the trash, degloved and without washing hands picked up a box of gloves, carried them to the chair along with a disposable towel, placed the towel on the arm of the chair and the stoma supplies on top of the towel. Without washing his/her hands LPN H regloved, picked up a disposable cloth and cleaned around the stoma site multiple times without changing the surface of the cloth. He/she threw the cloth away, removed his/her gloves and without washing his/her hands attached the [MEDICAL CONDITION] bag to the stoma wafer and laid it back on the towel. He/She picked up the skin prep/adhesive and applied it around the stoma site. He/She fanned the area with his/her hands. Soft stool was noted coming from stoma so LPN H regloved and wiped the stool with a disposable towel, threw it in the trash, and then without washing hands and changing gloves, picked up the wafer with the bag and applied it over the stoma. 7. Review of Resident #31’s POS, dated 4/19 showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] 0.2% opthalmic- one drop both eyes two times daily for [MEDICAL CONDITION] (5/25/18); -[MEDICATION NAME] ophthalmic drops 0.5% one drop to both eyes two times daily (5/25/18). Observation on 4/9/19 showed Certified Medication Technician (CMT) I completed the following: -At 3:45 P.M., he/she retrieved the resident’s [MEDICATION NAME] eye drops from the medication cart, entered the resident’s room, handed the resident a Kleenex and without gloving, administered one drop of medication into each of the resident’s eyes. CMT I did not wash or sanitize hands after the procedure or before exiting the room; -At 4:00 P.M. he/she re-entered the resident’s room with [MEDICATION NAME] drops, washed hands and without donning gloves, handed the resident a Kleenex and administered one drop of medication to each of the resident’s eyes. CMT I did not wash or sanitize hands after the procedure or before exiting the room. 8. Review of Resident #35’s POS, dated 4/19 showed the following: -[DIAGNOSES REDACTED].>-[MEDICATION NAME] 0.2% eye drops- one drop both eyes three times daily for [MEDICAL CONDITION] (9/14/17); -[MEDICATION NAME] ophthalmic 0.5% apply to both eyes two times daily for open angle with borderline findings (9/14/17). Observation on 4/9/19 showed CMT I completed the following: -At 3:52 P.M. CMT I retrieved Resident #35’s [MEDICATION NAME] eye drops from the medication cart, entered the resident’s room), and without donning gloves, administered one drop of medication into each of the resident’s eyes; -He/She did not wash or sanitize hands after the procedure or before exiting the room; -At 4:05 P.M. he/she re-entered Resident #35’s room with the [MEDICATION NAME] drops, washed hands and without donning gloves, administered one drop to each eye. He/she did not wash or sanitize hands after the procedure or before exiting the room. During interview on 4/12/19 at 4:25 P.M. CMT I said the following: -He/she should have worn gloves to administer eye drops; -Hands should be washed before and after eye drops are administered, with glove changes and before exiting a resident’s room. During interview on 4/12/19 at 5:05 P.M the Director of Nurses (DON) said she would expect staff to wear gloves when administering eye drops and to deglove and wash hands prior to exiting the room and before entering another resident’s room. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265816 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER SCHUYLER COUNTY NURSING HOME | STREET ADDRESS, CITY, STATE, ZIP 1306 US HIGHWAY 63 | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 36) 9. Review of Resident #37’s POS dated 4/1/19 showed the following: -[DIAGNOSES REDACTED].>-Blood sugar test at 6:30 A.M., 11:30 A.M., 4:00 P.M. and 8:00 P.M. daily. Observation on 4/10/19 at 6:55 A.M. showed the following: -Registered Nurses (RN) C entered the resident’s room and laid a plastic box of cotton balls, lancets and alcohol swabs, a notebook, and a plastic bag of supplies directly on the bottom bed sheet on the resident’s unmade bed; -RN C opened the plastic box and removed cotton balls and a lancet. He/she left the plastic box opened and lying directly on the bottom bed sheet on the resident’s unmade bed; -RN C cleaned the resident’s finger with alcohol, stuck his/her finger with the lancet, checked the resident’s blood sugar level and placed a cotton ball on the resident’s finger; -RN C picked the notebook up off the resident’s bottom bed sheet and wrote in the notebook, placed the bag of supplies in the resident’s bedside table, closed the plastic box of lancets, cottons balls and alcohol swabs and entered Resident #31’s room; -RN C laid the plastic box directly on Resident #31’s recliner chair, opened the plastic box, removed supplies and checked the resident’s blood sugar level. During interview on 4/10/19 at 7:00 A.M. and 4/11/19 at 11:00 A.M. RN C said the following: -Each resident had their own glucometer machine and it was kept in a plastic bag in the resident’s bedside table. The plastic box contained alcohol swabs, cotton balls, and lancets and was kept on the treatment cart. He/She took the box into each resident’s room and used the supplies while checking the resident’s blood sugar; -He/She should only take into each resident’s room the supplies needed and not the entire plastic box of supplies. He/she should place the blood sugar monitoring supplies on a barrier on the resident’s bedside table and not directly on the resident’s bed linens. Moving the plastic box from one resident room to another room was an infection control issue. 10. Observation of the facility showed the following: – On 4/9/19 at 9:30 A.M. no alcohol based hand cleanser or hand hygiene instructions at the entrance for visitors to the facility; -On 4/10/19 at 4:00 P.M. no alcohol based hand cleanser or hand hygiene instructions at the entrance for visitors to the facility; -On 4/11/19 at 1:00 P.M. no alcohol based hand cleanser or hand hygiene instructions at the entrance for visitors to the facility; -On 4/12/19 at 9:00 A.M. a bottle of alcohol based hand cleanser sat near the copy machine located just inside the facility front door. No hand hygiene instructions were posted at the entrance or near the bottle of alcohol based hand cleanser for facility visitors. | |
