In a certification survey dated December 17, 2009 on the New York State Department of Health (DOH) website, Bishop Charles Waldo Maclean Nursing Home in the Far Rockaway section of Queens received numerous deficiences, ranging from pressure sore treatment to substandard overall safety measures.
The surveyors found that the facility did not ensure that a resident with pressure ulcers received the necessary dietary assessment, treatment and re-evaluation to prevent the development of new pressure ulcers (bedsores, decubitis ulcers) and failed to promote healing of the existing ulcers. The Nursing Readmission Assessment dated 6/19/09 documented “. . .skin dry and intact” and listed the GT site as the only skin problem.
The comprehensive care plan for Pressure Ulcers dated 6/24/09 documented a 13 Braden Score (scale used to predict pressure sore risk). The Braden Risk Assessment documented that a score of 13 placed the resident “at moderate risk” for pressure ulcer development. The pressure ulcer care plan documented interventions to prevent pressure ulcer development and maintain skin integrity.
A pressure ulcer Flow Sheet dated 6/24/09 identified a Sacral Stage II Pressure Ulcer measuring 1 centimeter (cm) x 1 cm . The physician’s interim order dated 6/24/09 documented a treatment to cleanse the sacral ulcer with normal saline, apply Dermafix Spray and a dry sterile dressing every shift. There was no documented physician’s progress note addressing the Stage II pressure ulcer until one week later when it was identified as a Stage IV on 6/30/09.
The pressure ulcer Flow sheet for the Sacral Pressure Ulcer dated 6/30/09 documented that the ulcer had deteriorated increasing in size to 7 cm x 4 cm. A Physician Progress Note dated 6/30/09 documented that the Sacral Ulcer was a Stage IV measuring 7 cm x 4 cm with 10% bloody drainage. There was no reference to any nutritional recommendations. There was no documented evidence of a Dietary Reassessment addressing the resident’s nutritional needs related the the deterioration of the pressure ulcer to a Stage IV on 6/30/09.
The following ulcers developed and deteriorated during the resident’s stay at the Queens facility:
Stage II Sacrum 1 cm x 1 cm-onset 6/24/09. 9/1/09-Stage IV 10.0 cm x 12.0 cm x 3.0 cm.
Right Heel closed Blister-onset 7/1/09. 9/1/09-Eschar Stage IV 8 cm x 5 cm.
Left Heel-Blackened discoloration 4 cm x 7 cm-onset 7/9/09. 9/1/09-5 cm x 4 cm.
Stage II Right Hip 0.5 cm x 0.5 cm-onset 7/20/09. 9/1/09-Stage IV 14 cm x 10 cm x 4 cm Stage II Left Hip 0.3 cm x 0.3 cm-onset 7/28/09. 9/1/09-Stage IV 7 cm x 6 cm x 1.5 cm.
The facility violated at least twenty-six sections of Title 42 (Public Health) of the Code of Federal Regulations. Prior entries in this blog have detailed several of the Code sections violated in this particular instance (bedsores, overrall care, etc.). Below please find a sampling of additional regulations Charles Waldo Maclean failed to comply with according to the survey:
- 483.70(h)(4): The facility must…maintain an effective pest control program so that the facility is free of pests and rodents (both live and dead roaches were observed on several occasions in several different areas of the facility)
- 483.35(d)(3): Food. Each resident receives and the facility provides food prepared in a form designed to meet individual needs
- 483.20(k)(3)(ii): The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident’s written plan of care.
Again, these are just several sections of the Code that this facility violated according to the DOH survey. The full list, which is too extensive to replicate here, can be found on the DOH website. The scope of Public Health Law violations that this facility has amassed is disturbing. Changes are certainly in order. Perhaps the DOH survey will serve as the impetus for the facility to reevaluate its standards and increase quality of care for its residents.