Articles Posted in Infection

Silver Lake Specialized Rehabilitation and Care Center received 66 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on July 22, 2020. The Staten Island nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to prevent infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A September 2019 citation found that Silver Lake Specialized Rehabilitation and Care Center failed to ensure such. The citation specifically describes a Registered Nurse who performed wound care for a resident “without performing hand hygiene,” specifically failing to wash her hands between cleansing the resident’s wound and putting on a new set of gloves. The citation goes on to describe instances in which “the nasal cannulas and nebulizer masks” assigned to two residents were not covered properly when the residents weren’t using him, as well as a surveyor’s observation that oxygen tubing was resting on the floor. A plan of correction undertaken by the facility included the counseling of the RN and the replacement of the nasal cannula and tubing.

2. A July 2018 citation also found that Silver Lake Specialized Rehabilitation and Care Center failed to properly comply with Section 483.80. The citation states specifically that for three residents with nasal cannula and one ventilator-dependent resident, partial oxygen tubings were observed resting on the facility’s floor. The citation goes on to state that a ventilator-dependent resident’s foley bag was uncovered and resting on the floor, and that the facility “did not provide documented evidence that it developed an adequate WMP (Water Management Plan) that clearly identifies areas in the facility that are at risk of growth and spread of legionella and other opportunistic pathogens.” The citation states that these deficiencies had the “potential to cause more than minimal harm.”

Verrazano Nursing Home received 14 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on July 22, 2020. The Staten Island nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ adequate infection-prevention measures. Section 483.80 of the Federal Code requires the establishment and maintenance, by nursing home facilities, of a program designed to prevent and control communicable diseases and infections. A December 2019 citation found that Verrazano Nursing Home failed to ensure such. The citation states specifically that a Licensed Practical Nurse “was observed on five different occasions” providing wound care to a resident without washing her hands or otherwise performing proper hand hygiene. In one instance, for example, she was observed cleansing a resident’s sacral wound that was “soiled with feces,” then removing her gloves and donning new gloves without washing her hand in between, in contravention of policies. The citation goes on to state that residents at the facility “were no provided with hand wipes, or taken to wash hands prior to eating meals,” also in contravention of policy. The citation describes these deficiencies as having the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the in-servicing of the LPN and the counseling of two CNAs concerning the need to ensure residents are given hand wipes before and after meals.

2. The nursing home did not guarantee residents’ right to freedom from physical restraints. Section 483.10 of the Federal Code provides nursing home residents with the “right to be treated with respect and dignity,” which includes a right to freedom “from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat… medical symptoms.” A December 2018 citation found that Verrazano Nursing Home failed to ensure such. The citation specifically describes a resident who “was observed with the use of seat belt on several occasions which the resident was unable to intentionally release the belt buckle.” The citation goes on to describe interviews with nursing staff who “did not identify the use of this device as a restraint,” and concludes that there was no medical justification for its use, nor any documented evidence of a physician’s order for its use. A plan of correction undertaken by the facility included the review and revision of the resident’s care plan.

Cortlandt Healthcare suffered 12 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 18 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020, including one citation over its infection control practices. The Peekskill nursing home’s citations resulted from a total of two surveys by state inspectors. The violations they describe include the following:

1. The nursing home fell short in its infection prevention practices. Section 483.80 of the Federal Code requires nursing home facilities to create and maintain programs designed to prevent and control infection, and to create a safe and sanitary environment for residents. A March 2017 citation found that Cortlandt Healthcare failed to ensure such. The citation states specifically that the nursing home “did not ensure that it implemented a system of surveillance and investigation to identify possible communicable diseases before they can spread to other persons in the facility for seven residents.” It goes on to state that the facility failed to report “cases of skin infection resembling scabies” to state health authorities. It goes on to describe residents with rash and itching symptoms that led the facility to suspect a scabies infestation. In an interview, the facility’s Director of Nursing said that Cortland Home had “no existing policy and procedure for reporting, investigating, and controlling scabies infestation before they can spread to other persons in the facility.” One of the residents suffering from the symptoms “was reported crying hysterically and stated she can’t take the itching anymore.” A plan of correction undertaken by the facility included the placement of affected residents on isolation precautions and the development of new facility policy.

2. The nursing home did not properly store and label medications. Section 483.45 of the Federal Code requires nursing homes to label drugs and biologicals “in accordance with currently accepted professional principles, and include… the expiration date when applicable.” An August 2018 citation found that Cortlandt Healthcare did not comply with such. The citation states specifically that the facility did not “ensure that medications were discarded and prevent their potential use beyond the expiration” in connection to one of three medication carts, in which an opened vial of a redacted medication “was found in use after the recommended discard date.” In an interview, the facility’s Licensed Practical Nurse in charge of medication administration “did not give any explanation was to why the expired… vial was not discarded after the 28 days.” A plan of correction undertaken by the facility included the discarding of the expired vial.

New York State Veterans Home at Montrose: Infection Citation, Covid Deaths

New York State Veterans Home at Montrose suffered 13 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 26 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. One of those citations detailed findings of deficient infection control practices. The Montrose nursing home’s citations resulted from a total of five surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not employ adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities are required to establish and maintain a program to prevent and control infection, one that is adequately designed to ensure residents a safe and sanitary environment. An August 2016 survey found that New York State Veterans Home at Montrose did not ensure the effective establishment and/or maintenance of an infection prevention and control program. The survey lacks additional detail on the citation, though it specifies that the scope of the deficiency was “widespread” and “pervasive throughout the facility”; that it had caused no actual harm and put no residents in immediate jeopardy, although it “has caused minor discomfort and has the potential to cause more than minimal harm”; and that it was corrected by the facility as of November 5, 2016.

A new edition of the Long Term Care Community Coalition Elder Justice Newsletter asks a simple question: does providing a nursing home resident breakfast in their soiled bed constitute harm? How about failing to provide a stop date for a resident’s psychotropic medication?

“No Harm” deficiencies refer to citations of rule violations at nursing homes in which health inspectors determined that the violations caused “no harm” to residents. As the LTCCC notes, data provided by the Centers for Medicare & Medicaid Service, which mandate minimum standards of care for nursing homes participating in their programs, show that more than 95% of nursing home health citations describe “no harm” deficiencies. The LTCCC argues, however, that these no harm citations reflect systemic failures to recognize the suffering of nursing home residents, which in turn results in systemic failures to hold nursing homes accountable through financial penalties. “In the absence of a financial penalty,” the newsletter states, “nursing homes may have little incentive to correct the underlying causes of resident abuse, neglect, and other forms of harm.”

The newsletter proceeds to provide instances of health violations in which regulators determined that no harm was done to the resident in question. For example:

Bronx Center for Rehabilitation & Health Care received 44 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 21, 2019. Those citations number 12 more than the statewide average of 32. The Bronx nursing home’s citations resulted from a total of six inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure that residents’ drug regimens were free from unnecessary psychotropic medications. Under Section 483.45 of the Federal Code, nursing home facilities must keep residents’ drug regimens free from the unnecessary use of any drugs that affect “brain activities associated with mental processes and behavior,” including anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics. A January 2019 citation found that the nursing home failed to ensure that one resident was free from an unnecessary antipsychotic medication, in contravention of facility policy dictating that residents residents receive medications “at the lowest possible dosage for the shortest period of time,” and that they only receive such medications “when necessary to treat specific conditions for which they are indicated and effective.” As a result of the citation, the facility instituted a plan of correction in which the resident’s psychiatrist recommended a reduced dosage of the medication in question.

2. The nursing home did not ensure an environment free of accident hazards. Section 483.25 of the Federal Code stipulates that nursing home facilities are to provide an environment as free as possible from accident hazards, as well as adequate supervision to prevent residents from sustaining accidents. An October 2018 citation found that Bronx Center for Rehabilitation and Health Care did not provide adequate supervision to a resident who had been assessed as “high risk for elopement” and consequently placed on visual monitoring every 15 minutes. The citation states that the resident “successfully eloped the facility” through its gate and was later returned by local police officers. The nursing home’s investigation of the incident concluded that it was the result of “inadequate supervision” by the security guard, as well as a dietary aide’s “delayed reporting” of the resident’s elopement.

Spring Creek Rehabilitation & Nursing Care Center received 33 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 21, 2019. Those citations number one more than the statewide average of 32. The Brooklyn nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not implement proper measures to treat, heal, and prevent pressure ulcers and bedsores. Section 483.25(c) of the Federal Code stipulates that nursing home facilities must ensure that residents who enter without pressure sores do not develop them unless their condition renders such unavoidable; and that residents with existing pressure sores receive proper treatment and services. A September 2018 citation found that Spring Creek Rehabilitation and Nursing Care Center failed to comply with this requirement in connection to one resident observed by a state inspector. That resident was specifically observed on numerous instances not wearing the protective heel device ordered by his physician and documented in his comprehensive care plan. The citation notes that the resident had a stage 3 pressure ulcer on his right heel, and as such was required to wear a pressure-relieving device or devices as appropriate. However, the resident was observed on multiple instances without the necessary devices, and the inspector states that “there were no skin checks or dressing changes occurring” at the instances in question. In an interview, a Certified Nursing Assistant said that “sometimes she forgets” to apply the resident’s protective devices and returns later to apply them.

2. The nursing home did not employ adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program” that creates a “safe, sanitary and comfortable environment.” A September 2018 citation states that the nursing home did not ensure such an environment, specifically by failing to clean or properly maintain “multiple areas in the laundry room.” An inspector observed that the room in question was not “in good repair or condition,” specifically noting that the walls contained chipped paint, that a drain behind a washing machine was dirty, that the drain was “littered with paper,” and that there was a presence of “brown colored” and stagnant water. The inspector also observed a clogged water drain, dust and water built up on the floor beside a washing machine, a sink with a dirty handle, and brown streaks on a washing machine and dryer. In an interview, the facility’s Director of Nursing stated that “she did not know why the laundry room was in such a condition.”

Brooklyn Gardens Nursing & Rehabilitation Center received 39 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. It also received a Department of Health fine of $11,000, in April 2011, over alleged violations of sections of the health code relating to the pressure sores and nutrition. The Brooklyn nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not provide adequate supervision to prevent elopement. Section 483.25 of the Federal Code stipulates that nursing home facilities must provide adequate supervision and assistive devices to prevent residents from sustaining accidents. A December 2016 citation found that Brooklyn Gardens failed to provide adequate supervision in an instance where a resident who had been placed on hourly monitoring “was able to walk out of the facility’s front gate undetected by staff.” The citation states that the resident exited through the facility’s front gate at 5:17PM on the evening in question, but a Registered Nurse Supervisor was not made aware of such until 9PM, at which point a missing resident alert was activated. The resident was returned to the facility by local police at about 12:57AM “with injuries of unknown origin.”

2. The nursing home did not take adequate infection prevention and control measures. Section 483.80 of the Federal Code states in part that nursing homes must “establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” An October 2018 citation described the facility’s failure to maintain infection control practices and procedures in two instances. In one, an inspector observed a resident’s oxygen tubing touching the floor, in contravention of protocol. In a second instance, an inspector observed a Licensed Practical Nurse neglecting to clean a glucometer after using it, also in contravention of protocol. The citation states that these deficiencies had “potential to cause more than minimal harm.”

The Paramount at Somers received 28 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 7, 2019. The facility was also the subject of a 2012 fine of $14,000 in connection to alleged violations of New York Code sections concerning nursing home residents’ right to be notified of their rights, rules, services, and charges; administrative practices and procedures; and nursing home facility medical directors. The Somers nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not ensure residents were provided with an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to maintain an environment as free as possible from accident hazards, with adequate supervision and assistive devices to prevent residents from sustaining accidents. An October 2018 citation found The Paramount did not provide frequent room checks and supervision of a resident who “had numerous falls in her room without injury.” The citation states that the resident’s care plan included frequent room checks as an intervention method to prevent falls, but such checks were not implemented, and the facility “did not determine if frequent checks were conducted or a potential contributory factor to the accident.”

2. The nursing home did not take adequate steps to prevent and control infection. Section 483.80 of the Federal Code stipulates that nursing home facilities must “establish and maintain an infection prevention and control program” that creates a safe and sanitary environment for residents. A February 2019 citation found that facility did not ensure staff followed proper hand hygiene so as to prevent infection. An inspector specifically observed a failure by staff to perform proper hand hygiene while feeding residents at mealtime and assisting residents with feeding. The inspector also observed a staff member change the dressing on a resident’s wound and then lift a “sterile dressing instrument package” without putting on new gloves or washing her hands after discarding the resident’s soiled wound dressing.

Cypress Garden Center for Nursing and Rehabilitation received 20 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 12, 2019. The Flushing nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide adequate supervision or assistive devices to prevent residents from falling. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments remain “as free of accident hazards as is possible” and to provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2016 citation found that Cypress Gardens did not ensure that a resident who had been identified as “High Risk” for falls received adequate supervision to prevent them. An inspector specifically found that in June 2016 the resident was observed on the floor after a fall, having “sustained abrasions to the forehead and left forearm.” According to the citation, the resident’s care plan interventions for falls included a chair alarm, but at the time he “did not have a bed or chair alarm in pace.” The citation found that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not implement proper measures to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to maintain and implement “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A September 2019 citation found that the nursing home failed to provide such in an instance when an eye doctor consulting at the facility “did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam.” An inspector observed the eye doctor wiping off an exam table with a paper towel and then placing his equipment bag on it while there were still “stains” on the table; the doctor then moved the table into a resident’s room, according to the citation, and performed an eye exam on the resident without performing hand hygiene beforehand, although he was observed performing hand hygiene afterward.

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