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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 30, 2020
Corrected date: December 18, 2020
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during abbreviated surveys (NY 394, NY 202 and NY 588) the facility did not ensure all alleged violations including abuse, neglect, exploitation or mistreatment were reported to the New York State Department of Health (NYS DOH) for 2 of 3 residents reviewed (Residents #1 and 4). Specifically, Residents #1 and 4 were involved in a sexual incident that was not reported timely to the NYS DOH as required. Findings include: The 1/2019 revised facility Policy and Procedure for Reporting and Monitoring of Accidents/Incidents documents the Incident Review Committee will review any incident involving alleged abuse, mistreatment or neglect, significant injuries of unknown origin, misappropriation of resident property, resident elopement or New York State Department of Health (NYS DOH) Reportable Incident. The Incident Review Committee includes the Assistant Administrator, Administrator, Director of Nursing (DON) and others as deemed necessary. Administrators, Director of Nursing, Medical Director and corporate management will be notified of all incidents that meet the criteria to be reported to the NYS DOH. The facility policy Prevention of Abuse, Neglect, Involuntary Seclusion, & Misappropriation of Property reviewed 6/2019, documents the facility abuse includes non-consensual sexual contact of any type. The facility will ensure all allegations of abuse will be reported immediately, but not later than two hours after the allegation is made. Resident #1 had [DIAGNOSES REDACTED]. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The 3/2/20 MDS assessment documented the resident had moderately impaired cognition, did not exhibit behaviors, and required extensive assistance for most ADL. The 4/2/20 Incident Report documented Resident #1 was discovered in Resident #4's bed. The resident's hands were on each other's private areas and they were engaging in sexual activity. During an interview on 9/23/20 at 12:39 PM, social worker #27 stated that she did not believe Residents #1 and 4 were able to consent to sexual activity. During an interview on 9/22/20 at 11:41 AM, the Administrator stated while she was compiling the documents requested by the surveyor for Resident #4, she discovered the incident was not reported to the NYS DOH and it should have been. During an interview on 9/23/20 at 12:23 PM, the Director of Quality Assurance stated she made recommendations to the Administrator and the Director of Nursing (DON) of what incidents were reportable to the NYS DOH. The Director of Quality Assurance stated she was on medical leave from 3/2020 to 6/2020 and the person who was covering for her during that time period was no longer working at the facility. She stated any resident to resident interaction including sexual interactions were reportable, including in the event the residents could not consent to sexual activity. She stated she had not reviewed the Incident Summaries from her absence to see if everything had been reported as required. The incident between Residents #1 and #4 should have been reported at the time it occurred. She stated the facility reported the incident to the NYS DOH on 9/22/2020. During an interview on 10/30/20 at 2:51 PM, the Administrator stated at the time of the incident between Residents #1 and 4, the Director of Quality Assurance was out on medical leave and the person covering for her was in training. The Administrator stated it was ultimately her responsibility to ensure incidents were reported timely. 10NYCRR 415.4(b)(1)(ii) | Plan of Correction: ApprovedNovember 19, 2020 This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Van Duyn Center for Rehabilitation and Nursing agrees with the allegations and citations listed on the statement of deficiencies. Van Duyn Center for Rehabilitation and Nursing maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Van Duyn Center for Rehabilitation and Nursing written credible allegation of compliance. By submitting this plan of correction Van Duyn Center for Rehabilitation and Nursing does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Van Duyn Center for Rehabilitation and Nursing reserves all rights to raise all possible contentions and defenses in any civil or criminal or administrative claim, action or proceeding. Nothing contained in this plan of correction should be considered as a waiver of any potential acceptable peer review, quality assurance or self-critical examination privileges which Van Duyn Center for Rehabilitation and Nursing does not waive, and reserves the right to assert in any administrative, civil or criminal claim, action or proceedings offers its responses, credible allegations of compliance, and plan of correction as part of its ongoing efforts to provide quality care to residents. F609 Reporting of Alleged Violations 1.What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The 04/02/2020 incident involving resident #1 and #4 was reported to the NYSDOH on 09/22/2020. Resident #1 is no longer a resident of the facility. 2.How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this practice. All potentially reportable incidents from 04/02/2020 through 11/10/2020 were reviewed to ensure that those that meet the criteria in the Nursing Home Incident Reporting Manual, (MONTH) (YEAR) were reported. No other instances were identified. 3.What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? The facility leadership team has been re-educated regarding the requirements for reporting incidents to the NYSDOH including notification of the administrator when the report has been submitted. The procedure for monitoring potentially reportable incidents has been reviewed and revised. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? All incidents will be reviewed by the administrator and director of nursing to ensure that incidents are reported according to the Nursing Home Incident Reporting Manual, (MONTH) (YEAR). The results of this review will be reported to the Quality Assurance/Performance Improvement committee. 4.The date for correction and the title of the person responsible for correction of each deficiency. Overseen by: Administrator Compliance date: December 18, 2020 |