Every finding on record at Helen Hayes Hospital R H C F

Based on observation, interview, and record review conducted during the Recertification Survey from 2/4/2025-2/7/2025, the facility did not ensure the development within 48 hours of baseline care plans for each resident that included the minimum healthcare information necessary to meet resident needs for and 1 of 1 resident (Resident #15) reviewed for hospitalization and 1 of 1 resident (Resident #169) reviewed for Anticoagulant Use. Specifically, for Resident #15 and Resident #169 the baseline care plan did not address the use of physician prescribed anticoagulants (medications to prevent or treat blood clots). The Findings are: The policy titled Anticoagulant Management dated 7/8/2020 documented the facility will ensure the safe use of anticoagulants in the entire hospital by monitoring for bleeding or hospital acquired thromboembolism and adjust or discontinue anticoagulant therapy following evidence-based guidelines. Resident #15 was admitted with diagnosis of Pneumonia, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease The 11/6/24 Physician Order documented Apixaban 2.5 mg (an anticoagulant) twice daily for Atrial Fibrillation. There was no documented evidence in the 11/6/24 Baseline Care Plan to address the use of anticoagulants or the instructions needed to provide effective care that included measurable goals and/or interventions related to risk for bleeding/bruising. 51647 Resident #169 was admitted with diagnoses including Congestive Heart Failure, Atrial Fibrillation (irregular heartbeat), and Pulmonary Embolism. The 2/3/25 Physician Order documented Apixaban 2.5 mg (an anticoagulant) twice daily for Deep Vein Thrombosis Prophylaxis. There was no documented evidence in the 2/3/25 Baseline Care Plan to address the use of anticoagulants or the instructions needed to provide effective care that included measurable goals and/or interventions related to risk for bleeding/bruising. During an interview and observation on 2/5/25 at 4:16 PM the Administrator stated there were no anticoagulant baseline care plans in the computer system but they stated in the resident baseline care plan there was a section titled Knowledge-Based and in that section it stated to monitor for bleeding. When the administrator attempted to view the baseline care plan interventions in the regular viewable settings where all nurses and certified nursing aides could view the plan, it could not be seen outside of the administrator's computer view. The Administrator stated they were not sure why the interventions did not transfer over into the all-viewer system. During an interview on 2/05/25 at 4:21 PM the Assistant Director of Nursing stated the admission nurse was responsible for creating and/or putting baseline care plans in the system. The Assistant Director of Nursing, stated care plans were updated once a week and reviewed weekly and as needed. The Assistant Director of Nursing was asked how staff would have been able to know what interventions or monitoring was needed for anticoagulants and the Assistant Director of Nursing stated, staff would have known what interventions to put in place based on the medication's prescribed, registered nurse critical thinking, and the residents condition. 10 NYCRR 415.11

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents or the residents' representatives were given timely written notification of the transfer and the reasons for the move in a language and manner they understood. There was no documented evidence in the resident's clinical record of a written notice of the transfer of 2 of 2 residents (#2 and #13) reviewed for hospitalization . The findings are: 1. Resident #2 is an [AGE] year old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment and screening tool) dated 1/11/18 indicated that the resident was cognitively alert. The resident was seen by the facility physician on 1/17/18 for low hematocrit and hemoglobin blood levels, three stools positive for blood, was having difficulty breathing, and that her [MEDICAL CONDITION] was worsening. The facility physician then ordered to transfer the resident to the hospital for further evaluation on the same date at 3:45 PM. Review of the resident's clinical record revealed no documented evidence that the resident or the resident's representative was notified prior to the transfer on 1/17/18 and until the time the resident returned to the facility on [DATE]. The unit Registered Nurse supervisor (RNS) was interviewed on 2/8/18 at 2:30 PM and stated that it is the responsibility of the Physician or the Physician's Assistant (PA) to notify the family and to document in the medical record of the resident's transfer to the hospital. The PA who was on duty at the time of the transfer, was interviewed on 2/8/18 at 2:35 PM and stated that he had verbally notified the resident's daughter but he had not documented in the resident's medical record that he had notified her. 2. Resident #13 is a [AGE] year old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] for evaluation due to an increasing white blood count and a chest x-ray which showed left lower lung infiltrate/pneumonia. The Admission Minimum Data Set (a resident assessment and screening tool) of 1/15/18 documented that the resident scored 7 out of 15 on the BIMS (Brief Interview for Mental Status; used to assess the resident's cognition and orientation) and suggested that the resident has severely impaired cognition. The laboratory values were reviewed by the medical provider on 11/8/17 and 11/13/17, and documented the results of increasing increasing kidney function blood levels. The Physician's note dated 11/13/17 had no documented evidence that the resident or family were made aware of the transfer to the hospital for evaluation. The facility MD was not available for interview. The resident's case manager (medical social worker) was interviewed on 2/9/18 at 2:00 PM and stated that the facility physician informs the resident or resident representative of the transfer or discharge. The unit Registered Nurse supervisor (RNS) was interviewed on 2/9/18 at 2:30 PM and stated that it is the responsibility of the Physician or the Physician's Assistant (PA) to notify the family and to document in the medical record of the resident's transfer to the hospital. The facility's admission packet containing the pamphlet titled Your Rights as a Transitional Care/ Skilled Nursing Unit Resident at Helen Hayes Hospital dated June 2010, which is given to residents and family members upon the resident's admission to the facility, stated that the nursing home must inform the resident and designated representative, verbally and in writing about bed reservation and readmission regulations at the time of the resident's admission to the facility and again at the time of transfer for any reason and/or for therapeutic leave. 415.3(h)(1)(iii)(a-e)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that for 1 of 5 residents (#6) reviewed for unnecessary medications that the attending physician acted upon or addressed the pharmacy consultant's recommendation regarding the resident's medications and document what actions were taken to address it. The finding is: Resident #6 is an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Admission Minimum Data Set (a resident screening and assessment tool) of 1/15/18, the resident was receiving an antidepressant, an anticoagulant and opioid medications 7 days a week during the assessment period. The pharmacy consultant conducted a medication regimen review on 2/05/18 and revealed that the resident was on [MEDICATION NAME] (an antacid) and [MEDICATION NAME] (a blood-thinner). The pharmacy consultant documented in her note that [MEDICATION NAME] interacts with [MEDICATION NAME] so a recommendation was made to change the [MEDICATION NAME] to [MEDICATION NAME]. The pharmacy consultant further recommended to the physician that he discontinue all current as needed laxative medications, change [MEDICATION NAME] 100mg to as needed for hard stools, and Sennakot as needed for constipation. There was no documented evidence in the medical record that the resident's physician had responded to the pharmacy consultant's recommendations. The Physician's Assistant (PA) who cares for the resident was interviewed on 2/08/18 at 12:15 PM regarding his response to the pharmacist's recommendations. The PA stated they had a conversation about it and went over the medications together. He stated he told the pharmacy consultant what changes he would make and what changes he wouldn't make and why. He stated he thought the pharmacist documented his response to her. The PA stated he does not document the response anywhere. The pharmacy consultant was interviewed on 2/08/18 at 12:51 PM and she stated that she writes the physician's or the PA's responses to her recommendations and the rationale, if indicated. She stated it is not part of the resident's medical record. She stated she keeps it with her and uses it when they have the quarterly meetings. At the time of the exit, the facility did not provide the documentation that was allegedly in her possession. 415.18(c)(2)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that for 1 of 3 residents reviewed for hydration (Resident #176), an in-depth assessment was conducted to determine and address the adequacy of the resident's actual daily oral fluid intake after the [DIAGNOSES REDACTED]. The findings are: Resident #176 was admitted to the facility on [DATE] for short-term rehabilitation services. The resident's admitting [DIAGNOSES REDACTED]. The resident's physician's orders [REDACTED]. The physician progress notes [REDACTED]. The resident's Admission Minimum Data Set (MDS; a resident assessment instrument) completed on 7/15/16 reflected that the resident had a recent [DIAGNOSES REDACTED]. This assessment provided no causative factors for the dehydration and made reference to the 7/11/16 initial dietary assessment as a source for additional information regarding this problem. The dietary assessment did not address the adequacy of the resident's fluid intake at the time of completion of the assessment and made no reference to the resident's [DIAGNOSES REDACTED]. There was no documented evidence that an on going monitoring of the resident's total daily fluid intake was done after 7/16/16, to determine if the resident was consuming adequate fluids in light of the use of [MEDICATION NAME], recent [DIAGNOSES REDACTED]. The resident was discharged to the community on 7/25/16. The physician's discharge orders included [MEDICATION NAME] 40 mg. daily. The MDS Registered Nurse was interviewed on 11/5/16 at 4:10 PM regarding the completion of the Care Area Assessment summary and revealed that it would be expected that an assessment of the resident's hydration status would include how much fluid the resident was actually consuming on a daily basis. 415.11(a)(2)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that 1 of 3 residents (Resident #176) reviewed for hydration, necessary care was provided to determine adequacy of daily fluid intake to prevent dehydration and health-related problems. Specifically, (1.) there was no plan in place to monitor and to assess the resident's total daily fluid intake after the resident was placed on a fluid restriction and treated for [REDACTED].) the admission comprehensive assessment, which occurred after the [DIAGNOSES REDACTED]. The findings are: Resident #176 was admitted to the facility on [DATE] for short-term rehabilitation services. The resident's admitting [DIAGNOSES REDACTED]. According to the 7/8/16 admitting physician orders, the resident was admitted on a diuretic, [MEDICATION NAME] 20 mg., which was increased to 40 mg. on that date for the treatment of [REDACTED]. On 7/11/6, in response to a low sodium level of 133 milliequivalents (or [MEDICAL CONDITION] or low blood sodium level; normal range is 135-145), the physician gave an order to restrict the resident's daily fluid intake to 1000 cc, which was 55% of the resident's daily estimated requirement reflected in the dietary assessment completed on 7/11/16. Additionally, on 7/11/16, the resident was noted to have a change in mental status. The nurses notes and the physician's orders [REDACTED]. The resident was not hospitalized and returned to the facility with a [DIAGNOSES REDACTED]. [MEDICATION NAME] was resumed on 7/12/16. The physician discontinued the [MEDICATION NAME] on 7/13/16 due to the [DIAGNOSES REDACTED]. There was no documented evidence that a plan was put into place to assess the adequacy of the resident's intake in light of the admitting [DIAGNOSES REDACTED]. According to the facility's policy, intake and output record should be initiated when fluid intake is restricted. The physician gave an order for [REDACTED]. The resident's Admission Minimum Data Set (MDS; a resident assessment instrument) was completed on 7/15/16 and reflected that the resident had a recent [DIAGNOSES REDACTED]. This assessment provided no causative factors for the dehydration and made reference to the 7/11/16 dietary assessment as a source for additional information regarding this problem. This dietary assessment referenced above did not address the adequacy of the resident's fluid intake at the time of completion and did not make mention of the [DIAGNOSES REDACTED]. There was no documented evidence that on going monitoring of the resident's total daily fluid intake was done after 7/16/16 to determine if the resident was consuming adequate fluids in light of the use of [MEDICATION NAME], recent [DIAGNOSES REDACTED]. The resident was discharged to the community on 7/25/16. The physician's discharge orders included [MEDICATION NAME] 40 mg daily. The dietitian was interviewed on 11/5/16 at about 11:30 AM and stated that nursing is responsible for monitoring intake and that she was not aware that the resident's fluid intake was low, as reflected by the Intake/Output records of 7/13/16 -7/16/16. The MDS Registered Nurse was interviewed on 11/5/16 at 4:10 PM regarding the completion of the Care Area Assessment summary and revealed that it would be expected that an assessment of the resident's hydration status would include how much fluid the resident was actually consuming on a daily basis. 415.12(j)

Based on record review and interview the facility did not ensure that parameters of nutritional status were maintained. Specifically, Resident #65 experienced a 10 lb. weight loss in one week that was not addressed in order to investigate the cause. This was evident for 1 of 2 residents reviewed for nutrition and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #65 was admitted to the facility on [DATE] for short term rehabilitation. The resident experienced medical deconditioning due to a surgical procedure to repair a rectal prolapse. Additional [DIAGNOSES REDACTED]. The resident was discharged to home on 7/8/14. Review of the MDS 3.0 dated 6/11/14 admission assessment revealed that the resident ' s height was 59 inches and her weight was 111 lbs. at the time of the assessment. She had no/unknown weight loss or gain in the past 1-6 months and she was on a therapeutic diet while a resident. She required set up and supervision only for eating and was noted to be edentulous (having no teeth). Review of the 30 day assessment dated [DATE] indicated that the resident's weight was 100 lbs. at the time of the assessment. Review of the weights since admission were as follows: 6/4/14 - 111 lbs. 6/7/14 - 110.5 lbs. 6/19/14 - 110.5 lbs. 6/27/14 - 110.5 lbs. 7/3/14 - 99.7 lbs. Review of the Dietary assessment dated [DATE] reported that the resident's appetite was good (75-100% eaten), chewing ability was normal, she was able to feed herself and was receiving a 2 gm. Sodium diet. Under Nutritional Assessment the following statement appeared "Noted pt. with good appetite. Intake appears adequate to meet estimated nutr. needs." There were no recommendations noted. The two follow-up visits by the CDN (Certified Dietitian Nutritionist) on 6/19/14 and 6/27/14 did not identify any weight loss for the resident. Based on the weekly weights noted above the resident's entire 10 lb. weight loss occurred between 6/27/14 and 7/3/14. Review of the resident's list of medications that she was receiving while in the facility, did not include any diruetic medications that might have been responsible for the weight loss. In an interview with the RN nurse manager on 10/24/14 at 9:45AM regarding the resident's 10 lb. weight loss she stated that if the CNA (Certified Nurse Aide) who was weighing the resident observed a weight loss, she should have to notified the nurse. The nurse would then document the weight loss in the "Notes" and notify the MD and the Dietitian. She reviewed the "Notes" at that time and stated that the nurse had not documented the weight loss. In an interview with the CDN at 10:15AM on 10/24/14 she stated that she was not made aware of the resident's weight loss. If she had been notified she would have recommended a reweight to verify the weight. If the weight was confirmed she would then investigate possible reasons for the weight loss. 415.12(i)(1)

Based on record review, interview and observation, the facility did not ensure that an intervention to prevent further weight loss was accurately monitored for effectiveness. This was evident for 1 of 2 residents reviewed for nutrition (Resident #21) and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #21 was admitted to the facility on [DATE] for short term rehabilitation for a pelvic fracture. Additional [DIAGNOSES REDACTED]. Review of the MDS 3.0 (an assessment tool) dated 9/21/14, admission assessment, indicated that the resident ' s weight was 139 lbs. and her height was 66 inches at the time of the assessment. There was no/unknown weight loss or gain in the past 1-6 months and she was not receiving a therapeutic diet. She required set up and supervision for eating and had no dental issues. The 30 day MDS 3.0 dated 10/12/14 documented the same height and weight. Monthly weights included a 9/15/14 weight of 139 lbs. and a 10/15/14 weight of 132 lbs. Based on this information the resident experienced a 7 lb. weight loss in one month. Review of the Nutritional Assessment/Care Plan follow-up dated 10/15/14, a recommendation for Ensure twice daily was documented to address the 7 lb. weight loss. The RN manager was interviewed on 10/21/14 at 12:15PM and stated that the resident was receiving a nutritional supplement, Ensure, twice daily for unintended weight loss. She further stated that the amount consumed was not being recorded. In an interview with the dietitian at 11:35AM on 10/23/14 regarding documentation of the supplement she stated that there was no documentation regarding how much the resident drinks. She stated that the nurses document tolerance to the supplement e.g. good, fair or poor. In an interview with the resident on 10/23/14 at 11:45AM she stated that she does not like the Ensure but she drinks it because "it's good for me." When asked about the second Ensure that is provided she stated she doesn't drink that one. She stated she "gives it back." During the above interview with the resident, there was a bottle of Ensure observed on resident's overbed table. At that time (almost lunch time) there was still Ensure left in the bottle. The amount that remained was not able to be determined since the bottle was not transparent. The nursing documentation regarding "Patient's tolerance to dietary supplement," was reviewed and tolerance was documented as "Good." Ensure was provided at breakfast and lunch and was recorded by the 7AM - 3PM shift. In an interview with the Nurse manager at 12:10PM on 10/23/14 she stated that she thought that "Good" meant that the resident was probably drinking a can and a half of the two cans per day. When she was told that the resident refuses the second can of Ensure and that she doesn't like the supplement, she stated that she was unaware of that. In an interview with dietitian on 10/23/14 at 12:20PM, when asked if the resident was consuming the Ensure she stated that she thought she was. When she was informed that the resident drinks one Ensure per day and not two, she stated that she was unaware of that. She also stated that she was did not know that the resident didn't like the supplement. There was no evidence that the Ensure supplement to prevent further weight loss was monitored accurately and evaluated as to the appropriateness intervention to prevent further weight loss. 415.11(c)(2)(i-iii)

Based on record review and staff interview, the facility did not ensure that Preadmission Screen Resident Reviews (PASRR) were completed prior to admission as required by State and Federal Regulations in order to determine whether nursing home placement was appropriate and whether or not specialized services were required during nursing home stay to address Mental [MEDICAL CONDITION] and/or Mental Illness needs. This was evident for four of thirty residents reviewed for PASRR (Residents #66, #95, #117 and #118) and resulted in the potential for more than minimal harm that is not immediate jeopardy. The findings are: Medical/clinical records for four of thirty residents (Residents #66, #95, #117 and #118) reviewed on 10/3/13 did not contain evidence that PASRR screening had been completed prior to nursing home admission, as required by State and Federal Regulations, to establish whether the nursing home placement was appropriate for the resident and whether or not Specialized Services were required to meet the needs of residents with Mental [MEDICAL CONDITION] and/or Mental Illness. The Assistant Director of Nursing was interviewed on 10/3/13 at 1:45 PM and was not aware of why PASRR screening was not performed for these residents prior to admission. 415.11(e)

Based on observation and interview, the facility did not meet all requirements in posting information regarding nursing staffing. Specifically, the facility did not post the total number and actual hours worked per shift by licensed and unlicensed nursing staff directly responsible for resident care and the resident census was not readily available on the posting . This resulted in the potential for no more than minimal harm. The findings are: During the initial tour of the facility on the morning of 10/2/13, the posted nursing staffing was observed in a clear plastic frame on the countertop of a nursing station desk. The information listed the number of nursing personnel per shift but not the actual hours worked during any given shift. Additionally, the census for the day was not observed on the posting. The Director of Nursing Services (DNS) stated that this was the staff posting for the day and shift and the census was written on the back of the posting. A number was then observed on the back of the posting but there was no explanation of what the number referred to. The DNS stated she was not aware that actual hours worked by nursing staff was to be included in the posting and that the daily census was to be posted in a manner that was clearly understandable to residents and visitors. 483.30(e)

Based on observation, record review and staff interview, the facility did not ensure that controlled medications are properly stored to prevent possible diversion. Specifically, items other than narcotics are stored in the narcotic cabinet. This was evident on Unit 1A. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: During initial environmental tour of Unit 1A on 12/21/11 at approximately 9:15 a..m. it was observed upon inspection that an envelope containing cash collection was stored on the top shelf of the narcotic cabinet which contained various controlled medications. In an interview with the unit Registered Nurse at this time as to why the cabinet contained items other than narcotics, she stated the narcotic cabinet is a safe place to keep the staff's holiday cash collection. A review of the facility policy on "Controlled Substance Distribution. Handling, and Control" revealed that "all controlled substances will be stored in the cabinets provided in the medication room and double locked. No other items should be stored with the controlled substances." 415.18(d)

Based on observation, record review and staff interview, the facility did not ensure that its infection control program is consistently implemented to prevent infection. Specifically, a treatment nurse did not use proper handwashing and gloving techniques during dressing changes of a surgical wound and a skin excoriation. This was evident for 1 of 3 residents reviewed for pressure ulcers. (Resident #1) This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #1 is a [AGE] year old female who was admitted to the facility on [DATE] for rehabilitation for arthroplasty/total right hip replacement secondary to osteoarthritis and rheumatoid arthritis. A review of the treatment order record dated 12/16/11 and 12/18/11 revealed to cleanse the right abdominal fold with normal saline and apply sterile gauze, and to cleanse the right hip with a cleansing agent and apply [MEDICATION NAME] ointment daily before dressing, respectively. During a dressing change on 12/22/11 at 9:45 a.m., the following was observed. The nurse used the same glove in opening a bottle of saline solution and in cleansing the surgical wound on the resident's right hip area. She then took a key from her right coat pocket to open the cabinet containing the [MEDICATION NAME] ointment. She then put on a pair of gloves which she took out of her pocket where she placed her keys. She then took 5 pieces of sterile gauze and applied them directly over the surgical wound after applying the ointment. She then removed her gloves and washed her hands for less than 8 seconds to prepare for dressing change of an excoriation on the right lower abdominal fold. Again, the nurse was observed to put on a pair of gloves which she took out of her pocket, poured saline solution on a piece of gauze and started cleansing the excoriation. Still using the same glove, she then took 3 pieces of sterile gauze which she unfolded, and then placed them directly over the excoriation. The treatment nurse was interviewed immediately after the procedure and did not provide any explanation regarding proper hand washing and gloving techniques. She acknowledged that her pocket contained other items such as keys, ball pen and a marker which may contaminate the clean gloves used in the dressing change. A review of the facility policy on handwashing revealed that all staff must wash hands for at least 20 seconds prior to initiating patient care or procedures and before and after applying and removing gloves. 415.19(a)(1-3)