Articles Posted in Infection

Midway Nursing Home received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Maspeth nursing home’s citations resulted from a total of six inspections by state surveyors, and number two more than the statewide average of 32 citations. The violations they describe include the following:

1. The nursing home did not provide adequate supervision to prevent residents from experiencing accidents such as elopement. Section 483.25 of the Federal Code states that nursing home facilities must provide an environment as free as possible from accident hazards. A December 2016 citation found that Midway Nursing Home failed to comply with this citation by providing inadequate supervision to prevent a resident from eloping from the facility. The citation states specifically that the resident had been “identified at risk for elopement and had a wander guard in place.” However, according to the citation, the resident in question “walked out of the facility unknown to staff.” In an interview, the facility’s Director of Nursing stated that the resident’s monitoring “should have been increased.” In another interview, the facility’s administrator stated that a surveillance camera had not recorded any data, but he “was not aware that the camera was not reco[r]ding.” The citation notes that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not take adequate measures prevent and control the transmission of infection. Under Section 483.80 of the Federal Code, nursing homes must “establish and maintain an infection prevention and control program” that ensures residents a “safe, sanitary and comfortable environment.” An April 2017 citation found that the nursing home failed to comply with this section in two instances. In one, an inspector observed a Licensed Practical Nurse neglecting to clean a reusable blood glucose finger-stick meter between residents. In another, an inspector observed four separate facility nurses using “improper handwashing techniques” while providing care to residents, including during the administration of medication and wound care. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

Peninsula Nursing and Rehabilitation Center received 47 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Far Rockaway nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not take adequate measures to minimize the risk of accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents an environment as free as possible from accident hazards, with adequate supervision to prevent accidents. A July 2017 citation found that the nursing home did not provide one resident with an assistive device necessary to mitigate the risk of accidents. The citation states specifically that the resident, who had been identified as “at risk for elopement,” was provided with a wander guard device to alert facility staff if the resident attempted to leave the facility. According to the citation, staff removed this device while the resident was being transferred to the local hospital, but did not put it back on the resident upon return. “The resident then left the facility undetected,” the citation states. According to the citation, this failure resulted in the “potential to cause more than minimal harm.”

2. The nursing home did not adequately implement infection control measures. Section 483.65 of the Federal Code requires nursing homes to design and maintain an infection control program that provides residents with “a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.” An April 2016 citation found that the nursing home did not ensure its infection control members were properly maintained so as to prevent the transmission of disease and infection. The infection states specifically that there was no documented evidence indicating that a resident had received a Purified Protein Derivative skin test since they were admitted to the facility, in contravention of facility policy. The facility’s immunization policies and procedures were reviewed and revised in response to this citation.

New Glen Oaks Nursing Home received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Glen Oaks nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure the potential for accidents was adequately minimized. Under Section 483.25 of the Federal Code, nursing homes must provide residents with adequate supervision to prevent accidents, and further ensure an environment as free as possible from accident hazards. An August 2017 citation found that New Glen Oaks Nursing Home did not provide an adequately accident-free environment, with an inspector specifically observing “an uncapped soiled razor… in an open box on top of [a] resident’s bedside table.” In an interview, the facility’s nursing supervisor stated that the facility’s Certified Nursing Assistants were “aware that razors are not to be left at residents’ bedside and should be disposed of,” and the facility’s Director of Nursing Services stated that the razor in question “should not be kept at the resident’s bedside.”

2. The nursing home did not take adequate measures to prevent the potential spread of 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 July 2018 citation found that New Glen Oaks Nursing Home failed to comply with this section. The citation specifically states that facility staff were observed assisting residents during mealtime “without washing or sanitizing their hands in the dining room.” For instance, a Certified Nursing Assistant was observed putting used and dirty trays on a rack, then cutting up a resident’s food, then pouring water into a cup and giving it to the resident, all without washing or sanitizing her hands. The citation describes this deficiency as “widespread” and as having the “potential to cause more than minimal harm.”

Queen of Peace Residence received 12 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Queens Village 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 adequately protect residents from neglect. Section 483.12 of the Federal Code ensures nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A March 2018 citation found that Queen of Peace Residence failed to protect residents from neglect. An inspector specifically found that a resident was “left unattended for 1 1/2 hours on a commode which was located in the resident’s room in an area where the resident’s call bell was not within reach.” A Certified Nursing Assistant stated that on the morning in question, her responsibility was to “cover the floor,” ensure “all residents go to Mass in the Chapel,” and then stay in the facility’s TV room with residents not attending mass; the resident in question was suffering from a cold and staying in her room, according to the CNA, who said “her mistake was that she did not knock on the door to… see if she was in her room.” Another CNA—who had covered for the first CNA while she was on break—had not informed her “that she put the resident on her commode,” according to the citation, which noted that disciplinary actions were administered to the CNAs involved and that CNAs and nursing staff were subsequently educated.

2. The nursing home did not adequately implement its infection control practices. Section 483.80 of the Federal Code requires nursing homes to create 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 March 2018 citation found that Queen of Peace Residence did not ensure staff followed its infection control practices. An inspector specifically found that a Registered Nurse “used a contaminated glove to smear ointment on a resident’s wound” during one resident’s pressure ulcer care. In an interview, the RN acknowledged that she used the incorrect technique, stating that “it was wrong to apply the ointment on the resident’s buttocks after contamination of the glove” and that she had to improve her treatment technique.

Seagate Rehabilitation and Nursing Center received 27 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 22, 2020. The Brooklyn 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 keep its residents free from the unnecessary use of physical restraints. Section 483.10 of the Federal Code ensures nursing home residents the right “to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” A November 2019 citation found that Seagate Rehabilitation and Nursing Center did not ensure that in a case where a resident was indicated for the use of restraints, facility staff implemented “used the least restrictive alternative for the least amount of time and documented ongoing re-evaluation of the need for restraints.” An inspector found specifically that there was a lack of documented evidence of an ongoing need by the resident for the use of an abdominal binder, that the resident was reevaluated for its use, and that behavior necessitating the use of the binder were documented by the facility. A plan of correction undertaken by the facility included an assessment of the resident’s need for the restraint, which found that she no longer needed it, and as such it was removed.

2. The nursing home did not adequately ensure the implementation of infection prevention and control practices. Per Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program.” A February 2018 citation found that Seagate Rehabilitation and Nursing Center did not maintain infection control practices in two instances. In one, an inspector observed a resident receiving oxygen through nasal cannula with part of the device’s tubing resting on the floor of their room. The inspector also observed a Licensed Practical Nurse pick up the tubing and put it on the resident’s bed’s side rail, rather than discarding it and replacing it with new tubing. In another instance, an inspector observed a Registered Nurse providing wound care to a resident without employing effective hand hygiene or other infection control practices, specifically neglecting to clean clean a table or wash her hands between removing her gloves and opening gauze. A plan of correction undertaken by the facility included the in-servicing of the staff members in question.