Good Samaritan Nursing And Rehabilitation Care Ctr

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified during a recertification survey for a resident with a skin condition. The resident, who had severely impaired cognition and was at risk for skin pressure ulcers due to antiplatelet medication use, was observed with a dressing on the left forearm that had dried blood from an open purpura. There was no documented evidence of a skin assessment, physician notification, or treatment order before the dressing was applied. Licensed Practical Nurse #3 was informed of the skin tear by a Certified Nursing Assistant but failed to notify the Registered Nurse Supervisor or the Physician, and did not obtain a treatment order. The nurse applied a gauze dressing to stop the bleeding but did not follow the facility's policy for changes in skin condition. The Director of Nursing Services confirmed that the nurse should have informed the Registered Nurse Supervisor and obtained a physician's order. The oversight in following proper procedures led to the deficiency noted in the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by regulations. This deficiency was observed during a recertification survey for two residents. The first resident, who had intact cognition and no physician's order for Hydrocortisone lotion, was found with an unlabeled bottle of the lotion on their nightstand. The resident could not recall the origin of the lotion, and multiple staff members, including nurses and a certified nursing assistant, stated they were unaware of the lotion's presence and would have reported it if they had seen it. The second resident, also with intact cognition, was observed with a cup containing four tablets on their overbed table after breakfast. The resident had requested the nurse to leave the medications in the room, intending to take them after eating. The nurse complied, leaving the medications unattended, which was against the facility's policy. The resident had previously expressed a desire not to self-medicate, and there was no physician's order allowing them to do so. The nurse acknowledged the mistake, and the unit supervisor confirmed that medications should not be left unattended. Interviews with the Director of Nursing Services and other staff highlighted that residents should not have medications stored in their rooms without supervision. The facility's policy mandates that all medications be locked and administered by licensed nurses. The failure to adhere to these protocols resulted in the observed deficiencies, as medications were not properly secured and were left accessible to residents without appropriate oversight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure resident rights to be free from neglect, as evidenced by the actions of a Licensed Practical Nurse (LPN) who did not follow protocol after a resident fell. The incident involved a resident who was at risk for falls and had a history of skin tears. On the day of the incident, the resident was found on the floor in the main dining room by an LPN who was passing medications. Instead of calling for a Registered Nurse (RN) to assess the resident, the LPN picked the resident up and placed them back into their wheelchair. The facility's policy requires that any accident or incident be reported immediately to an RN, who must assess the resident for injuries and determine the need for immediate intervention. However, this protocol was not followed, as the LPN acted independently without notifying an RN. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognitive skills, was later assessed by an RN Supervisor and found to have a laceration on the forehead and ecchymosis on the cheek and knee. Interviews with staff confirmed that the LPN acknowledged the mistake of not calling an RN before moving the resident. The Assistant Director of Nursing and other staff members reiterated that the LPN should have left the resident on the floor until an RN could perform an assessment. This failure to adhere to established procedures resulted in the resident not receiving an immediate assessment by an RN, which is a violation of the resident's rights to be free from neglect.

Plan Of Correction

Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **ELEMENT 1** The Nurse Practitioner and family were notified of the incident on 6/8/24. Resident #1 new orders: normal saline cleanse and [MEDICATION NAME] to facial injury and left open to air, 1:1 supervision, neuro checks for 24 hours. 30 minute checks in place to monitor resident and prevent future falls. Resident #1 assessed on 6/10/24 by Nurse Practitioner. No obvious injuries noted, but x-rays to bilateral knees, elbows, humerus, and cervical spine were ordered and completed on 6/10/24 with no acute abnormalities. Resident #1 was seen by the social worker on 6/10/24 and psychology on 6/11/2024. Upon review by Administration and the Assistant Director of Nursing, LPN #2 was placed immediately on investigative suspension and was later terminated. LPN #1 was interviewed and counseled regarding policy and procedure and the RN assessment requirement. Facility self-reported the incident to the NYSDOH. **ELEMENT 2** To ensure there were no other residents affected since 6/8/24: All residents with an Accident/Incident that occurred from 6/2024 to present will be reviewed to ensure Policy and Procedure were followed and RN Assessments were performed on all Accidents/Incidents upon discovery. **ELEMENT 3** The following measures will be instituted to prevent reoccurrence: Resident #1 Plan of Care was reviewed on 6/10/24 with no findings. The Accident/Incident Policy was reviewed on 6/10/24 and was found to be in compliance with no revision necessary. All employees will be re-educated regarding the Accident/Incident Policy and Procedure with emphasis on not moving the affected resident until the RN Assessment has been completed and staff are given direction by the RN. All employees will be re-educated on the Abuse, Neglect and Mistreatment Prohibition Policy. All Accident/Incidents for the next 6 months will be reviewed to ensure RN Assessment and compliance with procedures to ensure 100% compliance. The Dayroom Supervision Policy and Procedure will be reviewed and revised. **ELEMENT 4** Performance monitoring to ensure Plan of Correction has prevented reoccurrence: Performance will be monitored weekly to review all Accidents/Incidents for compliance with the Accident/Incident Policy. An audit tool was created to monitor RN assessment compliance with all Accidents and Incidents. The percentage of compliance regarding Accident/Incident Review for 6/24 through 1/25 will be reported to the next PI Committee meeting. The percentage of compliance regarding all future reviews 2/25 through 7/25 will be reported quarterly to the PI Committee. **ELEMENT 5** The Plan of Correction will be completed by: 2/28/2025 Responsibility: Laura Pauze, RN, DON