Articles Posted in Infection

Daleview Care Center received 19 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 27, 2020. The Farmingdale nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not implement adequate measures to protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are maintained “as free of accident hazards as is possible” and to provide residents with “adequate supervision and assistance devices to prevent accidents.” A November 2016 citation found that Daleview Care Center did not ensure such in one of its two facility buildings. An inspector specifically found that one building “no exit alarm system in place for the front and back exit doors for residents who utilized a wanderguard.” Although the building’s back doors had exit alarms, according to the citation, they did not have alarms that were triggered by the devices, and the front doors did not have exit alarms. A plan of correction undertaken by the facility included the transfer of a resident with a wanderguard to a more secure building.

2. The nursing home did not comply with food safety standards. Section 483.60 of the Federal Code stipulates that nursing home facilities must “Store, prepare, distribute and serve food in accordance with professional standards.” A December 2017 citation found that Daleview Care Center did not maintain all equipment in its two kitchens in a clean and sanitary fashion. An inspector specifically observed a “heavily soiled” stainless steel dish machine “with dried-on splashes and in need of thorough cleaning”; a heavily soiled stainless steal box covering part of the kitchen’s Ansel system; and a heavily soiled broiler rack and pan. A plan of correction undertaken by the facility included the cleaning of the relevant equipment. 

A Holly Patterson Extended Care Facility received 23 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 14, 2020. The Uniondale nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The facility did not protect residents’ right to be free from the use of unnecessary psychotropic medications. Under Section 483.45 of the Federal Code, nursing homes must ensure that “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record,” and, among other things, that facilities attempt non-pharmacological interventions before administering such drugs. An October 2019 citation found that A Holly Patterson Extended Care Facility did not ensure this right for one resident. The citation states specifically hat the resident was ordered to be administered a redacted psychotropic medication, although there was “no documented evidence of non-pharmacological interventions attempted prior to the start of the antipsychotic medication.” A plan of correction undertaken by the facility included the in-servicing of the facility’s social worker and some nurses.

2. The nursing home did not implement proper measures to prevent and control the spread of infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program” that ensure residents a safe, sanitary environment. A June 2018 citation found that A Holly Patterson Extended Care Facility did not ensure such. The citation specifically states that an observer found that for four of the facility’s resident use buildings with potable water systems, the facility “did not conduct water sampling for Legionella quarterly as recommended by their Water Management Plan.” In an interview, the facility’s Vice President of Facilities indicated that he would contact the facility’s water management company to ensure regular testing in the future. The citation states that this deficiency had the “potential to cause minimal harm.”

Rockville Skilled Nursing & Rehabilitation Center received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 14, 2020. The Rockville Centre nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately treat and care for residents’ pressure ulcers and bedsores.  Section 483.25 of the Federal Code requires nursing homes ensure that residents with pressure ulcers receive “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure one resident with pressure ulcers received such. The citation states specifically that although a nurse noted the resident’s bilateral heels had “discoloration and were soft and tender,” the Registered Nurse’s full assessment of that resident’s heels “was not relayed to the physician in a timely manner, resulting in a delay in treatment.” In an interview, the Registered Nurse Supervisor stated that she had assessed the resident and documented her findings, but “forgot to write a progress note,” and then passed the findings to a wound nurse. In an interview, that nurse stated that she told the RN supervisor that a note had to be put in the resident’s medical record, and further that told the facility’s Assistant Director of Nursing Services about the resident’s condition, who “wanted to wait for the progress note to be written.”

2. The nursing home did not take adequate measures to prevent residents from being administered unnecessary psychotropic drugs. Section 483.45 of the Federal Code requires nursing homes to ensure that “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure residents taking medication for a redacted condition received gradual dose reductions, “unless clinically contraindicated, in an effort to discontinue these drugs.” The citation specifically describes one resident who was prescribed an antipsychotic medication, Quetiapine, and whose psychiatrist and pharmacy consultant “both recommended a tapering of the medication.” However, according to the citation, “there was no documented evidence that the physician took any action” to implement this recommendation. A plan of correction undertaken by the facility included the implementation of the drug’s dose reduction.

Sands Point Center for Health and Rehabilitation received 35 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 15, 2020. The Port Washington nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care and treatment. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with pressure ulcers “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A July 2018 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for one resident. The citation states specifically that “there was no documented evidence that a skin condition to the sacrum was assessed or received treatment until five days after the resident was admitted to the facility.” In an interview, the facility’s wound nurse stated that she had not seen the resident until several days after a note was left for her about the wound, and that “the wound should have been treated sooner.” The facility’s Medical Doctor stated further, in an interview, that “the doctor should have been called over the weekend and a treatment initiated.”

2. The nursing home did not take adequate measures to protect residents from the use of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes are required to keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for three residents. The citation goes on to state specifically that one resident was administered an antipsychotic medication despite an absence of any “documented justification or attempts at non-pharmacological intervention”; that another resident was administered an antipsychotic medication without an appropriate diagnosis and that a third resident was administered multiple drugs, including an antipsychotic, without an appropriate psychiatric diagnosis. The citation states that this deficiency had the “potential to cause more than minimal harm” to residents.

The Grand Pavilion for Rehab & Nursing at Rockville Centre received 26 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 19, 2020. The Rockville Centre nursing home’s citations resulted from a total of six surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not ensure residents were protected from involuntary seclusion. Section 483.13 of the Federal Code stipulates that nursing home residents have a right to freedom from “verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.” A May 2016 citation found that The Grand Pavilion for Rehab & Nursing at Rockville Centre did not ensure such for one resident. The citation states specifically that the resident was “not provided access to the dining room and offered activities of choice,” per the resident’s wishes. The citation goes on to state that the resident was “placed on isolation,” although there was no clinical indication for such. A plan of correction undertaken by the facility included the addition of the resident to the facility’s dining room seating plan.

2. The nursing home did not ensure resident drug regimens were free of unnecessary psychotropic drugs. Section 483.45 of the Federal Code stipulates that nursing homes must keep residents’ medication regimens free from the unnecessary use of medications that influence “brain activities associated with mental processes and behavior,” including anti-psychotic drugs. An October 2018 citation found that The Grand Pavilion for Rehab & Nursing at Rockville Centre did not ensure one resident was kept free of such. The citation states specifically that the staff administered an anti-psychotic medication to the resident for ten days even though the medication was intended for another resident. A plan of correction undertaken by the facility included the discontinuation of the medication and the in-servicing of the facility’s Registered Nurse regarding relevant policy.

Schulman and Schachne Institute for Nursing and Rehabilitation suffered 26 fatalities from Covid-19 as of June 23, 2020, per state records. The nursing home also received 12 citations finding it violated public health code between 2016 and 2020, according to health records accessed on June 24, 2020. One of those citations concerned infection control procedures. The facility has also received a 2012 fine of $12,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding accidents and the maintenance of residents’ nutritional status. The Brooklyn nursing home’s citations resulted from a total of 3 surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not take adequate measures to prevent infection. Section 483.80 of the Federal Code stipulates that nursing homes must establish and maintain an infection prevention and control program in order to ensure residents a safe and sanitary environment. A February 2018 citation found that Schulman and Schachne Institute for Nursing and Rehabilitation did not ensure such. The citation states specifically that a surveyor observed an uncovered oxygen mask and tubing “wrapped around the metered oxygen valve, and exposed to room air.” The surveyor also observed two residents’ Foley catheter tubes touching the facility’s floor. Both were in contravention of infection prevention and control best practices. A plan of correction undertaken by the facility included the re-education of relevant staff.

2. The nursing home did not ensure physician consults were completed in a timely manner. Section 483.30 of the Federal Code stipulates that nursing homes must ensure a residents’ primary care physicians review the resident’s program of care in a timely fashion, including specialist consultations. A June 2017 citation found that Schulman and Schachne Institute for Nursing and Rehabilitation did not ensure such. The citation states specifically that when a resident requested a podiatry consult and subsequently received it, their primary physician was not made aware of it until over a week later. As such, the citation states, a treatment recommended by the podiatrist was not promptly implemented. A plan of correction undertaken by the facility included the implementation of a policy to address prompt notification of primary care physicians regarding consultants’ recommendations.

The Phoenix Rehabilitation and Nursing Center suffered 17 fatalities from Covid-19 as of June 23, 2020, per state records. The nursing home also received 32 citations finding it violated public health code between 2016 and 2020, according to health records accessed on June 24, 2020. One of those citations concerned infection prevention and control deficiencies. The facility has also received a 2010 fine of $4,000 in connection to findings in a 2009 inspection that it violated health code provisions regarding accidents and administrative practices. The Brooklyn nursing home’s citations resulted from a total of 5 surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately implement infection prevention and control protocols. Under Section 483.80 of the Federal Code, nursing homes must create and maintain infection prevention and control programs. An October 2019 citation found that The Phoenix Rehabilitation and Nursing Center did not ensure such. The citation states specifically that employees did not wear proper personal protective equipment when they entered the room of a resident on contact precautions, and that the facility’s Infection Prevention and Control Program had not been reviewed and/or revised since a redacted year. The citation goes on to describe a Licensed Practical Nurse entering the room of a resident on contact precautions with only a mask over her nose and mouth, and no gown. She was observed checking a resident’s identification band and applying a cuff to the resident’s arm “without the use” of gloves she was holding in one of her hands, which she through away after checking the resident’s blood pressure. The resident was observed coughing and covering her mouth, according to the citation, but “was not encouraged or reminded to wash her hands after coughing into her hand.” The resident was observed wiping her nose with a tissue, placing it on a table, and then extending her fingers for a fingerstick test, but the LPN “did not encourage the resident to wash her hands after wiping her nose and before doing the fingerstick test,” according to the citation. A plan of correction undertaken by the facility included the educational counseling of relevant staff.

2. The nursing home did not follow food safety standards. Section 483.60 of the Federal Code stipulates that nursing homes must store and prepare food “in accordance with professional standards for food service safety.” An October 2019 citation found that The Phoenix Rehabilitation and Nursing Center did not ensure such. The citation states specifically that internal temperatures of cold foods were not maintained at professional standards. An observer noted various sandwiches at temperatures above the standard maximum temperature of 41 degrees Fahrenheit, the citation states. In an interview, the facility’s Food Service Director said that “the sandwiches should be stored in the 2 inch pan shingles in the refrigerator.” A plan of correction undertaken by the facility included the discarding of the offending sandwiches and the replacement of the sandwich refrigerator.

Autumn View Health Care Facility has received 18 citations over violations of public health code between 2016 and 2020, according to health records accessed on July 13, 2020. The Poughkeepsie nursing home’s citations resulted from a total of four surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not employ adequate infection control procedures. Section 483.80 of the Federal Code mandates that nursing homes must establish and maintain infection prevention and control procedures so as to ensure residents a safe and comfortable environment. A July 2019 citation found that Autumn View Health Care Facility did not ensure such. The citation states specifically that while caring for a resident, a Certified Nursing Assistant “did not change gloves and wash hands after cleaning feces prior to washing another area on the resident.” The citation goes on to state that the CNA touched surfaces in the room with contaminated gloves. According to the citations, all of the above conduct was in contravention of facility infection prevention and control policy. A plan of correction undertaken by the facility included the disinfection of surfaces in the room and the counseling of the CNA.

2. The nursing home did not take adequate measures to protect residents from abuse. Section 483.12 of the Federal Code stipulates that nursing homes must ensure residents are free from abuse, including verbal abuse. A May 2018 citation found that Autumn View Health Care Facility did not ensure such for one resident. The citation states specifically that a Certified Nursing Assistant “verbally and mentally abused the resident and used an obscene gesture toward the resident.” According to the citation, another CNA witnessed the incident, but did not immediately report it to facility staff. A plan of correction undertaken by the facility included the counseling and disciplining of the offending CNA.

Rome Memorial Hospital suffered 14 fatalities from Covid-19 as of July 12, 2020, per state records. The nursing home also received six citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 13, 2020, including two concerning its infection prevention procedures. The Rome 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 did not take adequate infection control measures. Section 483.80 of the Federal Code stipulates that nursing homes must create and maintain infection prevention and control programs that ensure residents a safe and sanitary environment. A September 2017 citation found that Rome Memorial Hospital did not ensure such. The citation states specifically that a nurse at the facility “did not disinfect a shared glucometer… with an approved disinfectant before, between, or after testing blood sugars” for two residents. In an interview, the LPN said that policy required that she wipe down the thermometer with a germicidal wipe or alcohol pad between resident uses, and that she usually used alcohol wipes, but that she did not in this instance because “she was nervous.” A plan of correction undertaken by the facility included the re-education of Registered Nurses and LPNs.

2. A January 2019 citation also found that Rome Memorial Hospital fell short in its infection control practices. According to this citation, a resident “was observed with his catheter tubing and collection bag uncovered and directly on the floor.” In an interview, a CNA stated that when the resident was in bed, the CNAs “hung his catheter on the side of the bed” and that it should not be touching the floor, as this posed an infection risk. A plan of correction undertaken by the facility included the in-servicing of staff on infection control practices related to drainage bags.

A new column in the New York Times discusses what the author calls a “rapidly growing phenomenon” in nursing homes and assisted living facilities during the Covid-19 pandemic: “lives stripped of human contact, meaningful activity, purpose and hope that things will get better in a time frame that is relevant to people in the last decades or years of life.” The most extreme cases of  this phenomenon involve “startling numbers of suicide attempts by older adults,” according to the author, a professor of medicine in San Francisco.

The suffering of elder Americans documented over the last few months includes deaths by neglect and starvation, hopelessness, and patients suffering from dementia “fighting draconian restrictions they cannot understand” and being sedated as a result, the column states. It cites one assisted living facility whose director said that after it ended group meals and activities, as well as visitors, its resident population experienced an increase in depression symptoms and suicidal thinking, and that more residents were “complaining of weakness and muscle atrophy, and more have had falls.” The author notes that suicide in elder care facilities was already increasing before the pandemic, arguing that circumstances are now “worse—much worse.”

While older adults who live at home may have the advantages of outdoor exercise and digital activities, “poorer people are less likely to have access to safe walks or digital solutions, and  they are more likely to live in smaller apartments or homes. And increasing numbers of older Americans live at home.” This is compounded by the enhanced risk of death from Covid-19 for elderly people, which compels many who could go outside to instead stay in. The author concludes that authorities advising citizens to stay inside are wrongfully treating the virus as “the only threat to health and well-being,” when elder citizens face other psychological threats that may be fatal for some.

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