New Gouverneur Hospital SNF

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) in a timely manner to an unresponsive resident who had full code status. This was evident in one (Resident #3) of three residents sampled for cardiopulmonary resuscitation. Specifically, on [DATE] at approximately 6:40 PM, staff entered Resident #3's room without emergency medical equipment after being alerted by a family member that the resident was unresponsive. Registered Nurses #11 and #12 failed to initiate any emergency response and action. As a result, approximately 15 minutes had passed before cardiopulmonary resuscitation was initiated, and ultimately, Resident #3 expired at 7:22 PM. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment are reported to the New York State Department of Health (NYSDOH). This was evident in one (Resident #3) out of three residents sampled for Abuse. Specifically, the facility failed to report an incident involving a delay to initiate cardiopulmonary resuscitation for Resident # 3 that resulted in death. The facility investigated the incident but did not report it to the New York State Department of Health.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure a comprehensive person-centered care plan was developed for each resident, that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #20) of 38 total sampled residents. Specifically, a care plan for a diagnosis of Major Depressive Disorder and the use of antidepressant medication was not developed for Resident #20.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that a resident's comprehensive care plan was reviewed and revised to reflect the resident's status. This was evident in 1 (Resident #217) of 8 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #217's comprehensive care plan was not revised to accurately reflect the resident's mode of transfer.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00351380) Survey from 12/12/2024 to 12/19/2024, the facility did not ensure each resident received adequate supervision to prevent accidents. This was evident in 1 (Resident #22) of 3 residents reviewed for Abuse out of 38 total sampled residents. Specifically, Resident #22, who was identified as high risk for falls and had history of numerous falls, was not provided adequate monitoring or supervision. On 08/13/2024 at 3:20 PM, Resident #22 stood up from their wheelchair and fell onto the floor while in the dining room.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the daily nurse staffing information included all the required information. Specifically, the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care. This was evident during the review of the Staffing task.

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure person-centered Comprehensive Care Plans (CCP) were developed and implemented for each resident to address the resident's needs. This is evident in 4 (Resident #s 93, 202, 222, and 184) out of 38 sampled residents. Specifically, there was no documented evidence 1) a CCP related to limited range of motion was developed for Resident #93, 2) a CCP related to side rail (SR) use was developed for Resident #202, 3) a CCP related to respiratory care was developed for Resident #222, and 4) a CCP related abuse prevention was developed for Resident #184.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure each resident remained free from physical restraints. This was evident for 1 (Resident # 194) of 8 residents reviewed for Activities of Daily Living out of a sample of 38 residents. Specifically, there were multiple observations of Resident #194 with bilateral 1/2 side rails (SR) in use without a Medical Doctor's Order (MDO).

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure a resident's comprehensive care plan (CCP) was reviewed and/or revised after each assessment and as needed for changing needs of the resident. This was evident for 2 (Resident #123 and Resident #230) of 38 sampled residents. Specifically, 1) multiple CCPs for Resident #123 were not reviewed and revised upon comprehensive assessment; and 2) the CCP related to Resident #230's risk for falls was not reviewed and revised after Resident #230 fell.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #93) of 1 resident(s) reviewed for Limited Range of Motion out of 38 sampled residents. Specifically, Resident #93 had a right hand contracture and was observed without a hand splint as per Medical Doctor Order (MDO).

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that a resident environment remained free of accident hazards. This was evident in 1 (Resident #202) out of 7 residents reviewed for Accidents/Hazards out of 38 sampled residents. Specifically, there were multiple observations of Resident #202 in bed with four 1/2 side rails (SR) raised.

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated survey(NY00242336), the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, a comprehensive person-centered care plan, and the resident's choices. Specifically, a resident admitted to the facility with a diagnosis of Diabetes Mellitus (DM) did not receive treatment and care for Diabetes management. This was evident for 1 of 1 resident reviewed for Quality of Care- Diabetes Management out of a total investigation sample of 38 residents (NY00242336) (Resident #438). The finding is: [...]

Inspectors wroteBased on interviews and record review conducted during the recertification and abbreviated complaint (NY00242336) survey, the facility did not ensure that the physician reviewed and documented a resident's total plan of care upon each visit. Specifically, the physician did not address diabetic managment needs for a resident's Diabetes or document any medical rationale for why Diabetic managment was discontinued. This was evident for 1 of 1 resident reviewed for Quality of Care- Diabetes Management out of a total investigation sample of 38 residents (Resident #438). The finding is: A facility policy and procedure related to Assessment and Reassessment of Residents dated 11/20/19 documented that the Medical Doctor is responsible for conducting an initial assessment inquiring information such as a History and Physical Examination. [...]

Inspectors wroteBased on observation, and staff interviews during the recertification survey, the facility did not ensure medical supplies containing biologicals were stored with appropriate pharmacy labels, following cautionary and expiration instructions. Specifically, 1 insulin pen was observed in a plastic bag without an open or discard date; and, 1 insulin vial was observed in a plastic bag 16 days after the documented expiration date (9 days after the manufacturer's recommended date). This was evident for 1 of 7 medication carts reviewed during the Medication Storage and Labeling facility task (10th floor).