Every finding on record at The Steven And Alexandra Cohen Ped L T C Pavilion

Based on record review and interview conducted during the recertification survey from 8/26/24 to 8/29/24, the facility did not ensure infection prevention and control standards were maintained. This was evident during the Infection Prevention and Control Program review. Specifically, the facility water management plan was dated May 2022 and there was no documented evidence that it had been reviewed or updated annually. The facility lacked the required facility Risk Assessment. The findings are: A review of the Legionella Control and Surveillance policy dated 8/1/2005 and last revised 11/01/2021 documented Blythedale Children's Hospital adheres to the Centers of Disease Control and New York State Department of Health recommendations regarding prevention, treatment and control of the hospital acquired Legionella. On 8/29/24 at approximately 2:00 PM, a request was made to see the facility's Water Management Plan and Risk Assessment. The facility produced a binder with a Water Management Plan dated May 2022 and no facility Risk Assessment was documented. During interview on 8/29/24 at 3:00 PM, a review was conducted of the facility Legionella binder with the Chief Operating Officer. There was no documented evidence of a facility Risk Assessment included in the Legionella binder. The Water Management Plan documented a date of May 2022. The Chief Operating Officer stated they had a water safety committee meeting on 7/24/24 during which they reviewed and updated the facility Risk Assessment and Water Management Plan. The Chief Operating Officer provided an electronic document of the facility Risk Assessment and Water Management Plan to the surveyors which was dated with the current date of 8/29/24. The Chief Operating Officer stated they do not print the documents. They stated the forms are live and when they view the forms, they will have the current date. The Chief Operating Officer stated they reviewed the documentation from the past two meetings and did not find documentation that the Risk Assessment and Water Management Plan was reviewed and updated. 10 NYCRR 415.19

Based on observation, interview and record review, conducted during an abbreviated survey (NY 726), the facility did not maintain an environment free of accident hazards and that each resident received adequate supervision to prevent accidents. Specifically, Resident #1 rolled off the shower bed on 8/18/2020. This was evident for 1 of 3 residents reviewed on accidents. The findings are: Resident is a 7-year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident has spastic and dystonic tetraplegic due to [MEDICAL CONDITION] from strangulation in a car. The Annual MDS (Minimum Data Set - a resident screening tool) dated 4/16/2020 documented: Brief Interview for Mental Status - not assessed which indicated that resident was severely cognitively impaired: was totally dependent with assist of 2 person for bed mobility, transfer, toilet use, personal hygiene and dressing, totally dependent with assist of 1 person with eating; always incontinent of urine and bowel; used wheelchair as mobility device. Falls Risk assessment dated [DATE] revealed a score of 14 which indicated that resident is at high risk for falls Comprehensive care plan for falls and injury dated 4/12/2020 documented: current progress, partially achieved; outcome progress comment: to remain free of falls and injury for the next 90 days, has been reviewed and revised. Facility ' s summary of investigation dated 8/18/2020 signed by DON and Administrator documented: On 8/18/2020 at 6:40pm, resident fell out of the shower bed in his room, as shower bed siderails were not up. Shower was found to be 27 inches from the floor. Resident is in persistent vegetative state and is dependent for all cares. Resident landed on his back. Shower bed removed from service. Nursing Supervisor and MD notified and assessed resident. Post fall, resident was awake and cried for approximately 2 minutes, head was stabilized, non-reactive to pain to on any extremities with light palpation, vital signs were stable, pupils were reactive to light. 911 was called. MD spoke with resident ' s parents. Staff did not move resident from floor. EMS transferred resident from floor to stretcher. Resident was transferred to WMC with CNA. CT scan of head and spine, within normal limits. Resident was assigned to CNA #1 and CNA #2. Resident had a large BM, which had soiled the bed and his clothes. Resident was transferred from the bed to the shower bed via 2-person lift. During the lift, the 2 CNAs stood between the bed and the shower bed to facilitate. Resident was undressed but still had chux underneath him. Once transferred in the shower bed, CNA #2 went ot discard of the soiled linen in a laundry hamper in the room. CNA #1 started to remove the chux and noticed that resident had BM on his back. When turning the resident away from her to clean him, resident fell off the shower bed. CNA #2 yelled out to CNA #1 as she saw resident falling. Per CNA #1, when she transfers to the shower bed, she leaves the siderail up and secured. The shower beds have inner linings that are separate from the siderails and the inner lining was up. CNA #1 was not aware the siderail was down when she began turning resident. Shower bed was inspected by Biomed and found in good working order. Resident ' s plan of care updated. Education on Carevo shower bed started with focus on ensuring the siderails are secured and locked prior to moving shower bed or turning resident. A quick reference shower guide is posted in the shower room and in the room. Clinical Nurse Educator is in contact with representative from shower bed vendor and will facilitate staff in-services. Both CNAs involved in the incident received education from DON n 8/19/2020, including focus on communication with co-worker during transfer and/or caring for resident, and ensuring siderails of stretcher are up and locked prior to turning resident. During in an interview DON on 3/25/2021 at 11:45am, she stated that on 8/ 2020 resident #1 was heavily soiled, the incident happened in his room with the shower bed. The shower bed had an inner flap/ liner with a lip but the actual siderails were down. Both the CNAs were in the room but when the resident fell , both CNAs were in the room, one CNA #2, was away from the bed because she was throwing our and getting rid of the soiled items into the hamper. They called the nurse and she responded and assessed the resident. The height of the bed was 27 inches, because it was measured. The CNAs were very forthcoming of the incident. One CNA had a lapse and thought that the siderails were up. During in an interview with CNA #1 on 3/25/2021 at 2:56pm, she stated that on 8/18/2020, she was assigned as CNA assist. She stated that they were doing evening change with CNA #2 and they went to resident #1 ' s room and saw a a large bowel movement, he was in bed covered with feces from head to toe, the feces was in liquid form. She said that they decided to give him a shower to clean off the feces. They took the shower bed form the shower room and transferred him to the shower bed with 2-person transfer, one person at the top and one person at the bottom. They undressed hm, they were wiping trying to wipe off as much as they could. CNA #2 walked away into the bathroom in his room a short walking distance, to place clothes in hamper. CNA #1 said she continued to clean Resident #1, she turned him into his side, and he rolled off the shower bed into the floor. The height of the shower bed was about 2 feet. She said they called the nurse RN #1 Leah Salinas. She called the supervisor. There was no injury. CNA #1 said she did not realize that the side rail of the shower bed was down, but the shower bed lining stayed up. She said that the siderail of the shower bed next to her was up but not on the other side and she didn ' t know that the siderail was down. During in an interview with CNA #2 on 3/26/2021 at 9:58am, she stated that she was assigned to resident #1 on 8/18/2020 on the 3-11 shift. She said that resident #1 was already comfortable, on her third rounds, about 9pm, although not sure of the time, she said that she realized resident #1 had a n explosion with bowel movement that went all the way to his back and it was best to give him a shower, even if resident was not on the 3-11 shift shower. She stated, she called her partner, CNA #1. She said they transferred resident #1 into the shower bed, he is a 2-person transfer. He is stiff, if you turn him, he could roll over. The siderail where he fell off was up but it wasn ' t clicked in to lock, they turned him on the side they took off everything including his pajamas and she went to the bathroom to rinse it off and her partner, CNA #1 started screaming, at that time resident #1 cried, he rolled over, it happened so fast. She said the shower bed was not too high. She said the siderail could go down completely and you could put it up, but you have to click it to lock it. She said that she thought they did it but she said that maybe when resident #1 rolled over it is his weight that caused the siderail to go down. During in an interview on 3/26/2021 at 10:54am, with RN #1, she stated that on 8/18/2020 she worked from 7am to 7:30pm, she was called by CNA #1 and CNA #2 and let her now that resident #1 had fallen when they were trying to get him to be showered. She said that when she reached the room, resident #1 was lying on the floor next to his bed, between his bed and the shower bed. She said that they stabilized him, the RN supervisor and the MD assessed him. His vital signs were stable. EMS was called and they came. Resident #1 had an explosive bowel movement from head to toe, the aides were trying to shower him. RN #1 said that the height of bed was 27 inches floor because she measured it, it was in its lowest position. She said that the shower bed was checked, and it was in good working order. The shower bed was put away to be checked by maintenance, and it was checked, and everything was okay. The staff had education by the company. RNS #2 said that what seemed to happen was that, the siderail of the shower bed was not clicked in a lock position, the CNAs must not have realized that the siderail was not in lock position. She said that she did not notice if the siderails of the shower bed were up when she reached the resident ' s room because she was focused on the resident. (483.25)

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that staff followed proper gloving and hand hygiene to prevent cross contamination and the spread of infection for 1 of 2 residents reviewed for respiratory care. (Resident #3). Specifically, 1 of 3 Registered Nurses observed did not perform proper hand hygiene while administering [MEDICAL CONDITION] care. The findings are: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS: a resident assessment tool) dated 4/3/19 documented the resident is ventilator dependent for respiratory care, receives [MEDICAL CONDITION] (trach) care and is dependent on staff for all activities of daily living (ADLs). The resident's plan of care dated 7/31/18 documented the resident will be free from signs and symptoms of infection. Interventions included; to assess for signs and symptoms of infection. A care plan progress note dated 6/29/19 documented sputum culture positive for pseudomonas- trachea, resistant to antibiotic. Multi Drug Resistant Organisms (MDRO) precautions initiated 6/20, care providers with potential exposure to sputum need mask, gown, gloves. Will continue to monitor for signs and symptoms of active infections and intervene as needed. A Critical Labs Progress note dated 6/24/19 and signed by the resident's Physician documented that on 6/20/19 Sputum culture-MDRO: Pseudomonas resistant to multiple antibiotics. MDRO precautions initiated. Care givers with potential exposure to sputum need mask, gown, glove. Physicians order dated 6/24/19 documented MDRO precautions, Pseudomonas, trachea, specifics; mask, gown, gloves for potential contact with sputum. A facility policy and procedure dated 9/2016 and revised in (YEAR), entitled Identification of Residents with Multidrug Resistant Organisms (MDRO) documented: it is the policy of the facility to provide treatment to residents with colonization of MDRO in a manner which minimizes the spread to other residents, staff and visitors. In addition to Standard Precautions, enhanced MDRO precautions are used for those residents identified with an MDRO. Procedures include Personal protective Equipment (PPE) (gowns, gloves) are utilized while providing care when contact with colonized bodily fluid is anticipated. A facility policy dated 5/89, revised (MONTH) 2019 entitled Hand Hygiene documented: The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. During an observation of the resident'[MEDICAL CONDITION] on 7/11/19 at approximately 9:50 AM, after performing hand hygiene and donning PPE, RN #1 was observed holding a staff hand held phone. Subsequently, RN#1 proceeded to assist in the residents'[MEDICAL CONDITION] without performing hand hygiene. RN #1 was interviewed on 7/11/19 at 10:17 AM and reported she should have removed her gloves, washed her hands and put on new gloves before providing care. 415.19(b)(4)

Based on observation, interview and record review conducted during a recertification, the facility did not ensure that the facility staff followed proper gloving and hand hygiene to prevent cross contamination and the spread of infection for 2 of 8 residents (#4 and #20) during a medication pass observation. Specifically, 2 of the 7 Registered Nurses (RNs) did not observe proper use of gloves and hand hygiene during medication passes in the West and South units of the facility. The findings are: 1. Resident #4 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS; a resident assessment tool) of 7/21/17, revealed the resident is ventilator dependent for respiratory support and required total dependence on staff for all aspects of care for activities of daily living (ADL). The Physician order [REDACTED]. A medication observation was conducted 8/21/17 at 1:06 PM on the South side unit and the following were observed: RN#1 prepared the above ordered medication and water flushes for the resident in the medication room and then transported them to the resident's room. RN#1 donned a pair of gloves and pulled the privacy curtains around the resident's bed. Wearing the same gloves, RN#1 turned on the light, touched the computer keyboard, and the hand-held medication bar code scanner during the medication verification process. RN#1 then applied hand sanitizer to the same soiled gloves and cleansed the diaphragm part of her stethoscope prior to checking for GT tube placement. RN#1 used the same contaminated gloves to administer the medication and water flushes via the GT tube without performing proper hand hygiene including the use of clean gloves. RN # 1 was interviewed immediately following the above observation and stated that she should have changed her gloves and washed her hands prior to administering the medication and water flushes. 2. Resident # 20 has [DIAGNOSES REDACTED]. The Quarterly MDS of 5/31/17 revealed the resident as ventilator dependent for respiratory support and was totally dependent on staff for all aspect of ADL care. The Physician order [REDACTED]. A medication observation was conducted on 8/21/17 at 1:38 PM on the West side unit and the following were observed: RN#2 prepared the ordered medication and water flushes for the resident at the medication station, then transported them to the resident's room. RN#2 donned a pair of gloves. RN#2 then pulled the privacy curtain around the resident's bed, touch the computer keyboard and the hand-held medication bar code scanner during the medication verification process. RN#2 used the same contaminated gloves to administer the medication and water flushes via the GT tube without performing proper hand hygiene including the use of clean gloves. RN#2 was interviewed on 8/21/17 immediately following the observation and stated that she should have changed her gloves and washed her hands prior to administering the medication and water flushes. 415.19 (a) (1-3)