Initial Comments:
A focused fundamental survey was conducted March 20 and 21, 2024 to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Regulations for Intermediate Care Facilities. The census during the survey was four, and the sample consisted of two individuals. Four deficiencies were identified as result of the survey.
Plan of Correction:
483.420(b)(1)(i) STANDARD
CLIENT FINANCES
Name - Component - 00
The facility must establish and maintain a system that assures a full and complete accounting of clients' personal funds entrusted to the facility on behalf of clients.
Observations:
Based on investigation report review and staff interview facility staff failed to follow facility established procedures that ensured a full and complete accounting of one individual's personal funds. (Individual #3)
Findings included:
1. Review of a facility investigation revealed that on October 9, 2023, House Manager pulled $60 from Individual #3's funds for an upcoming outing. The $60 was placed in an envelope in a locked safe which is stored in a locked filing cabinet in Individual #3's residence. House Manager stated the safe and filing cabinet remained locked until October 12, 2023, and then they were unlocked on October 13, 2023. Filing cabinet and safe remained unlocked until October 17, 2023 when Individual #3's $60 was discovered missing.
2. Review of the investigation further revealed that no staff interviewed were able to say they knew anything about the missing funds. The money was never found or accounted for. Funds were replaced from the facility into Individual #3's account. The House Manager was retrained on current policy to keep money locked in the safe until it is designated to a staff for an outing.
3. The QIDP was interviewed on March 21, 2024 at 10:30 AM. During the interview the QIDP confirmed the facility staff failed to follow facility established procedures that ensured a full and complete accounting of Individual #3's personal funds.
Plan of Correction:With regard to Item 1, the house manager failed to secure a locked cabinet containing money belonging to Individual #3. A certified investigation into this incident was initiated; however, it was unable to be determined what happened to Individual #3's money. Individual #3's funds were replaced by the facility. The house manager was retrained on 11/17/2023 about safe money handling policies and keeping wallet money locked in a safe until it is designated to a staff for an outing. In addition to retraining, an updated Wallet Money Procedure was developed on April 2, 2024 and implemented, effective immediately. This procedure requires all residential wallets be kept in a locked safe in the house manager's office. Two staff must verify all money being signed in and out. All expenditures must have a receipt. House Managers will maintain a ledger for each individual and their wallet money. House Managers will submit the ledgers and wallets to the QIDP at the end of the month for reconciliation. The QIDP will keep copies of all wallet ledgers and receipts. House Managers will also be responsible for completing routine wallet checks to ensure all money is accounted for at least twice weekly. Routine wallet checks will be documented by the house managers and submitted to the QIDP with the other end of month documentation. The ICF Supervisor and QIDP will complete random checks of documentation to ensure routine wallet checks are being completed. Effectiveness of these new procedures will be evidenced by no further accounts of missing wallet money. The QIDP will have overall responsibility for these interventions.
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on facility incident report review and staff interview, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies towards the health needs for two individuals in the sample. (Individuals #1 and #4).
Findings included:
1. Individual #1
a. An incident report dated October 19, 2023 was reviewed March 20, 2024. This review revealed that Individual #1 was being assisted out of the wheelchair van by staff. Staff raising the lift walked away from lift when it was only halfway up to assist another individual. Second staff pushing Individual #1 out of the back of the van did not realize the lift was only halfway raised. Individual #1 fell backwards out of the van in her wheelchair. She was belted into her wheelchair and landed on the right side. Individual #1 sustained a swollen spot above her right eye and a significant bruise to her left outside buttocks area.
2. Individual #4
a. An incident report dated October 12, 2023 was reviewed on March 20, 2024. This review revealed that Individual #4 was transferred by staff from the shower chair to his bed. Staff then left Individual #4 on his bed to move the shower chair and Individual #4 fell face down on the floor. Individual sustained a dime sized scrape swollen area to his forehead.
3. The QIDP was interviewed on March 22, 2024 at 10:30 AM. During the interview the QIDP did not ensure that staff demonstrated the necessary skills and competencies towards the health needs for two individuals.
Plan of Correction:With regard to Item 1-a, Individual #1 was being assisted out of the wheelchair van by staff. Staff raising the lift walked away with the lift only raised half-way in order to assist another individual. Second staff pushing Individual #1 out of the wheelchair van was unaware the lift was not secure for Individual #1, causing the wheelchair to fall backwards out of the van and Individual #1 sustaining injury. Day Program staff were retrained by their supervisor on wheelchair lift safety and communication on 10/20/2023. All staff will be trained on van and lift safety at the April 18th, 2024 team meeting.
With regard to Item 2-a, Individual #4 was being transferred by staff from the shower chair to his bed. Staff then left Individual #4 on his bed to move the shower chair and Individual #4 fell face down on the floor sustaining injury. A memo was put out to staff following this incident notifying them to lay Individual #4 on his bed if they have to step away when assisting him with personal care, to ensure no falls occur. Staff were retrained on this protocol at the team meeting held on October 19th, 2023. All staff will be retrained on this safety measure again at the team meeting on April 18th, 2024. Effectiveness of these interventions will be evidenced by no further incidents related to wheelchair van safety or falls out of bed. The QIDP will have overall responsibility for oversight of this intervention.
483.460(c) STANDARD
NURSING SERVICES
Name - Component - 00
The facility must provide clients with nursing services in accordance with their needs.
Observations:
Based on documentation review, staff interviews and observation, the facility failed to provide nursing services in accordance with one individual's needs. (Individual #4).
Findings included:
1.Individual #4
a. Review of the facility's incident and accident reports and clinic record revealed that Individual #4 was hospitalized from November 24, 2023 to November 28, 2023 with a diagnose of COVID pneumonia. As a result of this diagnosis the individual was on continuous oxygenation and had a decline in ambulation. The individual required extensive assistance from staff for bed mobility , transfers and hygiene. The individual was incontinent and dependent on staff for toileting needs. A wheelchair was used for mobility. Individual was at moderate risk for pressure sores.
b. A 24-, 36-, and 72-hour report done by nursing following discharge from the hospital revealed that the buttocks was red, and Destin creamy ointment was applied as needed.
c. According to the facility incident report Individual #4 had a small pink spot on his buttocks on December 10, 2023. The prescribed Destin ointment was applied as needed and an appointment was made with his primary care physician for December 14, 2023. The physician ordered to apply a duoderm dressing and diagnosed the area as a stage 2 pressure injury of the right buttocks. After visit summary notes that he had two small skin breakdowns on the right buttocks measuring 2-3 MM each. A certified investigation was conducted as result of the pressure area.
d. Interview with the house manager and QIDP on March 20, 2024 revealed that there was no documentation available to verify that repositioning was done every two hours from November 28, 2023 until December 10, 2023 when the open area was noted. On January 15, 2024, documentation was implemented for staff to sign off on every two hours to indicate repositioning and care was completed. Interview with the Qualified Intellectually Disability Professional (QIDP) revealed that staff failed to identify and monitor a Stage 1 pressure area before it advanced to Stage 2 pressure area.
2. Interview with the Qualified Intellectually Disability Professional (QIDP) on March 21, 2010 at 9:00 AM confirmed the facility failed to provide nursing services in accordance with one individual's needs.
Plan of Correction:With regard to Items 1a-1c, Individual #4 was discharged home on November 28, 2023, after a 4-day hospitalization. Nursing staff completed a 24, 48, 72-hour post hospitalization assessment on individual #4 and noted that his buttock was red, and his PRN Desitin ointment was applied as needed. On December 10, 2023, a small pink spot was noted on his buttocks. The prescribed Desitin continued to be applied as needed and at a doctor's appointment on December 14, 2023, Individual #4 was diagnosed with a stage 2 pressure injury. A certified Investigation was completed, and it was determined that due to Individual #4's limited mobility and need for assistance that additional documentation to verify repositioning was necessary. On January 15, 2024, 2-hour check, change and repositioning documentation was implemented for Individual #4 and all individuals who require this level of assistance. Additionally, on April 1, 2024, a referral was made to the HCQU for Individual #4 in regard to a second concern related to pressure injuries on 03/28/2024. All staff, including nursing, will be retrained on skin integrity and pressure injuries at the April 18, 2024, team meeting. These interventions will be evidenced by Individual #4 and all other individuals maintaining healthy skin integrity. The Health Services Supervisor will have overall responsibility for these interventions.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on staff interview and incident report review, it was determined the facility failed to ensure three individuals' medications were administered without error. (Individual #2 , individual #3 and Individual #4)
Findings included:
1. Individual #2
a. On April 4, 2023 , Singular was omitted.
2. Individual #3
a. On October 6, 2023, during medication administration, Individual #3 was given another individual's vitamins and minerals.
3. Individual #4
a. On May 21 and May 22, 2023, Individual #4 received 2 extra doses of Lipitor that was discontinued.
4. The above-referenced errors resulted in a total of four medication administration errors, from April 4, 2023 to October 6, 2023.
5. Interview with the QIDP on March 20, 2024 at 10:30 AM and documentation review, indicated the above-referenced individuals did not experience any ill effects as a result of these medication errors.
6. The QIDP was interviewed on March 20, 2024 at 10:30 AM. During the interview the QIDP confirmed the above-mentioned findings.
Plan of Correction:With regard to Item 1-a, Individual #2 went on therapeutic leave with family and it was discovered that Singular was missing from the cassette for 04/04/23. The ICF Supervisor completed retraining for staff on the proper procedure for sending medications home with family for an individual. Staff was retrained to check each cassette thoroughly and to compare the medications in the cassette to the MAR to ensure all medications are accounted for. On 2/16/24, a contract was signed with Tarrytown Pharmacy. As of April 1, 2024, we now have the ability to contact the pharmacy to have medications packaged for individuals with planned Therapeutic Leave. These medications will be packaged in individual blister packs rather than medication cassettes which will offer a more effective method to checking and ensuring all medications are present.
With regard to Item 2-a, on 10/6/2023, Individual #3 was given medications (vitamins and minerals) belonging to another individual. The House Manager retrained staff committing the error on 10/25/23. This retraining consisted of a review on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List. In addition to retraining, staff received 2 additional practicum observations to ensure all medication administration procedures are being followed correctly.
With regard to Item 3-a, Individual #4 had a prescription for Lipitor that was discontinued by their doctor; however, the medication was not discontinued in the MAR and removed from the medication cassettes until 2 days later. This resulted in Individual #4 receiving two additional doses of the medication after it had been discontinued. The nurse responsible for discontinuing the medication and notifying staff of the change was counseled by the Health Services' Supervisor on 05/24/23. The nurse was also retrained on the proper procedure for removing discontinued medications from the cassettes and MARs as soon as a change is made.
All staff will receive additional training related to the ICF Medication Administration procedures and medication pass checklist. This will be completed by the ICF Supervisor/Medication Trainer, at the April 18, 2024, team meeting. All health services' staff will be retrained on prompt discontinuation of medications from the MAR and communication of these changes at the April 11, 2024, Health Services' Meeting. These interventions will benefit Individuals #2, #3, #4 and all other individuals by no further incidents of medication errors.
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