DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
331551 A. BUILDING __________
B. WING ______________ 		11/05/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
STATEN ISLAND UNIVERSITY HOSPITAL UNIV HOSPICE 78 MEISNER AVENUE, STATEN ISLAND, NY, 10306
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0517      
41671 Based on clinical record review and staff interview the hospice failed to ensure that all patients were protected and free from injuries of unknown sources. This was evident in one (1) of three (3) clinical records reviewed. (Patient #1). Failure to protect and keep all patients free from injuries of unknown sources has the potential for negative patient outcomes. The Findings are: Patient #1 has a Start of Care date of 08/17/2019 with the following diagnoses: Malignant neoplasm of unspecified part of unspecified bronchus or lung for certification period 08/17/2019 - 11/15/2019. 08/24/2019 Visit Information. 16:00 - 00:00 LPN Shift Summary. Clinical Assessments: LPN Observation: E-Signed on 08/25/2019 01:06. LPN Narrative Documents: " ....2345 pt. was found by staff sitting on the floor in front of her bed .... The staff and I picked her from the floor and put her back to bed. Pt was able to walk back to bed. No known injury noticed. Pt is noticed to be confused at the time of the fall, bed alarm was in place but despite reorient pt to ring call bell she always turned off alarm. All siderails were up before pt was found on floor. Spacers were put on bed and resident aid is currently sitting with pt." 08/26/19 LPN Observation: Visit Time: 0800- 16:00 E. signed: 15:52 Found pt. OOB, bed alarm sounding. Assisted to BR, .... OOB to recliner with chair alarm in use and 1:1 companion at bedside. 08/26/19: 14:55 RN Comprehensive Assessment: POC: 08/ 17/19: Apply/provide assistive device for ambulation. Fall prevention in place. Result: Performed: Pt. S/P fall, ongoing fall prevention. Musculoskeletal: Musculoskeletal S&S: Falls, Unsteady Gait, Weakness ("Pt. fell over the weekend. Patient states she was hurrying to the bathroom and fell. Upon exam no bruising, no discoloration or ecchymosis areas seen. Patient stated she landed on her buttocks. RN reminded patient to use call bell for OOB assistance. Patient needs ongoing reminder. Pt. is getting weaker. Pt. has nonskid socks applied, one on one companion with patient during the day, call bell, side rails, bed and chair alarm in place, bed spacer in place, frequent monitoring. Reviewed with staff LPN, PCA, to be continued with the other shifts"). Hospice Aide POC: Reviewed and updated. Special Instructions: "Patient is at risk for falls, must be accompanied for all out of bed needs, ongoing reminder to use call bell, bed and chair alarm must be in on position at all times. 08/30/2019 04:31 LPN Observation:" Wound status is opened. The wound is 2 in. Wound Exudate appears Bloody and the amount is scant. The Peri wound tissue is Pink/normal for ethnic group, Intact. The wound color is Pink, Red, Other" Mental: Forgetful, Hx Dementia, Unsteady gait". 08/30/190 04:31 LPN Narrative: "Pt is very confused and forgetful - constant supervision is needed - pt. rested in bed with all rails up and bed alarm placed for safety- she was extremely restless- trying to get out of bed - she did not sleep - Pt. was found by RA (Resident Assistant) sitting in the bed - the rail insert was taken off and was lying on the mattress - the Pt. had a 2 inch cut above her right eyebrow - o/c ( On Call) rn (Registered Nurse) was notified - the cut was washed with normal saline - bacitracin and a dry dressing was applied - she also advised to keep the Pt. awake now in case of a concussion- am care was given Pt. was washed and changed as needed- she was assisted with all adls- ...a head to toe assessment was done and no other bruises or cuts were seen - when pt. was questioned she claimed to have no idea how the insert was removed- and she had no idea that she was cut above the eyebrow and she no recollection of how the cut got there -". The Clinical record lacks documented evidence that the patient was continuously supervised to prevent and protect from injury. There is no documented evidence of an incident report that documents the fall on 08/24/2019. There is no documented evidence of an Aide's Plan of Care. On 11/5/19 the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.
L0545      
41671 Based on clinical record review and staff interview the hospice failed to ensure that all patient's Plan of Care are individualized, patient - specific, and integrate changes based on assessment findings. This was evident in one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure that all patient's Plan of Care are individualized, patient - specific, clear, concise and integrate changes based on assessment findings has the potential for negative patient outcomes. The Findings are: Patient #1 has a Start of Care date of 08/17/2019 with the following diagnoses: Malignant neoplasm of unspecified part of unspecified bronchus or lung for certification period 08/17/2019 - 11/15/2019. 08/30/2019 Visit Time: 0800 - 1600: 0840 LPN Observation: LPN Narrative documents: " ... Requesting to get OOB to BR. C/O pain in right knee and left 1st & 2nd toes. Unable to bear weight on right leg ...." 08/30/2019 visit time: 10:30 - 11:00 E-Signed 17:35 RN Focused Assessment:" Pain: Is there an immediate Need for Pain management? No (Pt. reports pain in rt knee when extended leg. No obvious injury, faint discoloration noted both knees. Can extend lt leg fully, knee clicks when leg fully extended.)" Pt. reports pain only when straightening rt leg which she is currently keeping flexed at knee. "Impaired Mobility (Pt. usually walks with supervision, currently c/o pain rt leg preventing attempt at ambulation.)" (clean laceration over right eye, no bleeding noted, old ecchymotic areas both knees.)" The RN's assessment failed to document a clear and concise assessment of the change in the patient's status, injury sustained and the patient's level of pain. On 11/5/19 the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.