Bishop Rehabilitation And Nursing Center
BISHOP REHABILITATION AND NURSING CENTER in SYRACUSE, NY — inspection on July 11, 2024.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F554.
Residents #21, #64, #72, #207, and #239 were not assessed to determine their ability to safely self-administer medications or had physician orders for self-administration of medication.
The facility's failure to ensure residents' medications were safely administered placed all 248 residents at risk for serious harm or serious adverse outcomes.
This resulted in Immediate Jeopardy to resident health and safety.
Pain Management Refer to the citation text under
F-F580):
- Resident #37 did not receive their Lyrica from the day shift (7:00 AM-3:00 PM) of 6/22/2024 until day shift of 6/24/2024 due to the facility not having the resident's ordered medication and the provider was not notified.
This resulted in putting residents who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care.
- Resident #147 refused heparin, insulin, and labs as ordered for a period of 6 months, the medical provider was not notified and there was not an assessment by the provider.
- Resident #153 had a low blood glucose level that was reported to the facility by the lab on 6/22/2024 and the provider was not notified.
This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety.
- Resident #528 had a change in condition and was not assessed by a qualified professional when the change was noted, the medical provider was not notified, and the resident's representative was not notified.
Subsequently, the resident was hospitalized with severe dehydration.
This resulted in harm to Residents #528 and #37 that was not immediate jeopardy.
Activities of Daily Living (
F-F677):
- Resident #154 did not receive oral hygiene as ordered.
- Resident #226 did not receive assistance with eating as care planned.
Pressure Ulcer Services (
F-F686):
- Resident #826 was readmitted from the hospital with pressure injuries of the sacrum and heel, the areas were not assessed by a qualified professional, and there were no treatments provided for the areas.
The resident was re-hospitalized on two subsequent occasions, had pressure injuries of the sacrum and heels, the areas were not assessed timely by a qualified professional or provided with treatments following readmission.
- Resident # 271 had orders for pressure relief boots to be worn while in bed and the boots were not applied.
Subsequently, the resident developed a deep tissue injury (localized area of purple/maroon discolored intact skin due to damage of underlying tissue) area to their right heel.
Additionally, there were wound care recommendations for a wheelchair cushion evaluation and for the resident's brief to be left open to air that were not implemented.
335338
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335338 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203
F-F688):
- Resident #64 did not have bilateral hand splints in place as ordered and care planned.
Maintaining Acceptable Parameters of Nutritional Status (
F-F692):
- Resident #133 had a significant weight loss and recommendations for an appetite stimulant were not discussed with the medical provider.
Respiratory Care (
Findings included:
The undated facility job description for the Facility Educator documented the Educator was responsible for planning, organizing, developing, implementing, facilitating, and evaluating all employee's education programs throughout the facility, in accordance with the Company's policies and procedures and current applicable Federal, State, Local standards, guidelines and regulations to assure the highest degree of quality resident care can be maintained at all times.
The essential functions of the role included working in collaboration with all facility department directors in the orientation and education of staff to ensure mandatory and regulatory education requirements were met within the facility; conducting competencies in areas of nursing practice with attention to management of the medically complex patient; regularly conduct education needs assessment for the facility to assist in identifying areas for improvement; assume the authority, responsibility, and accountability of directing the in-service educational programs as required or directed for compliance with Federal, State, and corporate policy.
They were to maintain attendance and documentation of in-services in accordance with regulatory guidelines and corporate policies.
The facility policy, Medication Administration, revised 1/2021, documented new personnel authorized to administer medications would not be permitted to prepare or administer medications until they had been oriented to the medication administration system used by the facility.
Newly licensed nurses would receive oversight on medication administration from current licensed nurses who would establish competency.
335338
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335338 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203
F-F697.
Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life.
This placed all residents with pain, who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care.
Provision of Medically Related Social Services Refer to citation text under
F-F745.
Residents #41, #126, #153, #235, and #250 were not provided medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care.
335338
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335338 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203
During an interview on 7/9/2024 at 1:23 PM, Nurse Practitioner #22 stated they worked with the Medical Director for [AGE] years.
The corporate administration did not include the providers in their administrative discussions.
Prior to the corporate takeover of the facility the provider had some input into the admission and services for incoming residents, the day to day operations of the facility, and the needs of the residents.
The providers used to be an integral part of the residents care and now they were not as involved.
They had medical staff meetings with administrative staff, pharmacy, and all providers.
The Medical Director oversaw the residents on 3 North.
The policies were all corporate policies.
During a telephone interview on 7/10/2024 at 2:25 PM, the Medical Director stated their responsibility was overseeing of physician services, ensuring the physicians were doing their mandated resident visits, and working closely with the Administration.
They were not responsible for overseeing care of every resident in the facility, they were an attending physician with their own case load of residents.
They currently did not have any input regarding facility policies.
They used to have to sign off on the policies and procedures and was advised of and made aware of policy and procedure changes.
They thought the facility was pulling most of the polices from the corporate level.
They had gone to the Director of Nursing when they had concerns about policies and procedures and felt they were not being heard.
They were unsure who to speak to beyond the Director of Nursing.
The facility corporation was a complex system and ran things in layers and was filtered down to the facility.
There were many people involved in who the facility would admit and how facility staff provided care to the residents.
They stated they had not heard about the facility assessment and had no input into that document. In the past they would review residents and decide if the facility was able to accommodate and appropriately care for the new resident.
The policies and procedures were corporate driven policies and they provided insight as requested but the corporation had their own way of doing things.
During an interview on 7/11/2024 at 8:52 AM, the Administrator stated the Medical Director participated in the quality assurance meetings, the plan of correction, and rehospitalization s meeting.
The policies come from the corporate team and the Medical Director should be aware of all the policies.
10 CRR NY 415.15(a)(1)(2)(3)
335338
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335338 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203
During an interview with the Administrator and Director of Nursing on 7/11/2024 at 8:52 AM, the Administrator stated the focus of education was on the plan of correction with policy and procedure updates.
They stated they held townhall meetings once or twice a month for all 3 shifts; where they discussed the plan of correction, advised where the facility stood with the Department of Health, and discussed how to avoid repeated deficiencies.
They identified areas of concern and was working on the record keeping for the facilities education.
They ensured all staff received mandatory trainings by having a good orientation process, with each Department Head presenting what was important to their department.
The administrator indicated the process for maintaining proper record of training was a work in progress and was not perfect.
The Administrator stated the role of the Administrator was to oversee the day-to-day operations of all the functioning departments.
They stated they were not a nurse or a clinician, but they should know about everything going on in the building with every department.
They had daily morning reports and group meetings to addresses certain areas.
They met with the Director of Nursing to discuss current processes and how to improve in certain areas. It was important to have thorough communication with the interdisciplinary team members, and they stated they made rounds on the resident care units.
The Administrator stated the Medical Director participated in the quality assurance meetings, the plan of correction, and rehospitalization s meeting.
The policies come from the corporate team and the Medical Director should be aware of all the policies.
During the same interview with the Administrator and the Director of Nursing on 7/11/2024 at 8:52 AM, the Director of Nursing stated the education program matched the needs of the residents identified in the facility assessment but was geared more towards the regulatory results.
The facility provided dementia care education, but not anything related to other mental health management.
The Director of Nursing stated the importance of having trained competent nursing staff was to ensure staff could give safe and quality care to the residents. It was important to ensure staff were trained completely prior to providing direct care to ensure competency.
The lack of competent staff negatively impacted their quality assurance.
An electronic communication from the Director of Nursing on 7/11/2024 at 11:15 AM, indicated they were unable to locate any staff files for Patient Service Liaison #108, Dietary Staff #112, Certified Occupational Therapy Assistant #116, and Authorization Specialist #121.
335338
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335338 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bishop Rehabilitation and Nursing Center 918 James Street Syracuse, NY 13203