Essex Center for Rehabilitation and Healthcare
January 25, 2019 Complaint Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during abbreviated surveys (Case #s NY 633 and NY 984), the facility did not implement a care plan that includes measurable objectives, interventions and time frames for how staff will meet resident needs for 2 (Residents #s 3 and 14) of 14 residents reviewed. Specifically, Resident #3 was care planned for one to one supervision while eating, but was left alone in his room, unsupervised while eating his meal. Subsequently, Resident #3 choked on his food. Additionally, Resident#14 was care planned to be transferred by a sling lift, but instead was transferred by the stand lift. Subsequently, Resident #14 fainted, and sustained a laceration under the right armpit. This is evidenced by: Resident #3 Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severe cognitive impairment, could usually understand and was usually understood. The Policy and Procedure (P&P) Assistance with Meals last revised 4/17, documented the levels of supervision and defined general supervision as being in the line of sight. One to one (1:1) supervision meant to stay with the resident always during meals until completion. The undated job description for Certified Nurse Aide, documented the resident plans of care were to be reviewed daily and CNAs were to perform all other related tasks as required, in accordance with established policies and practices. A facility-wide inservice dated 10/23/18, on Supervision for Meals was given to all staff and defined 1:1 supervision as having physical presence with the resident while eating, and not leaving the resident alone. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL) Eating initiated 7/27/18, documented the resident required 1:1 Supervision, set up help, and staff stand by assistance. Resident #3's care card for ADLs-self-feeding dated 7/27/18, documented the resident needed the limited assistance of one person, and standby assistance. The care card did not list 1:1 supervision as documented on the comprehensive care plan. A Nurses Note dated 10/21/18 at 10:54AM, written by Licensed Practical Nurse #1 (LPN#1) documented Resident #3 choked on his pancake at breakfast. She heard someone calling for help in the hallway and saw Resident #3 standing outside of his room holding his throat, his eyes widened, unable to speak and pale looking. She started the [MEDICATION NAME] maneuver and after three attempts, the resident could speak and regained some color. The resident stated he choked on his pancake. During an interview on 1/10/2019 at 3:20PM, the DON stated she had audited every care plan on every resident. She did an audit on 10/23/18, for all residents needing supervision for eating and an in-service was provided for all staff on the Policy and Procedure for Supervision for Meals. During an interview on 1/11/19 at 9:50AM, CNA#1 stated she brought the resident's tray into his room and left his room to pass more trays. She stated she did not know that she had to stay with him until he finished his meal. During an interview on 1/11/19 at 10:10 AM, CNA#2 stated she saw Resident #3 with his hand around his throat and called out that he was choking. LPN #1, was right across the hall and came out to the hallway and gave the resident the [MEDICATION NAME] maneuver. CNA#2 stated she knew how to provide care for the resident by checking the care card inside the closet door. Resident 14 Resident #14 was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact, could understand others and made herself understood. The Policy and Procedure entitled How to use a Mechanical Lift last revised 7/2017, documented the staff must be trained and be able to demonstrate competency using the specific machines or devices utilized in the facility including sling lifts and sit-to-stand lifts. In addition, the resident's condition would first have to be assessed to determine if they could tolerate using the mechanical lift for transferring. The Certified Nurse Aide (CNA) Job Description documented the resident's plan of care was to be reviewed daily, and CNAs were to perform all other related tasks as required, in accordance with established policies and practices. The Comprehensive Care Plan (CCP) for Transfers dated 6/16/2017, documented the resident required a sling lift, not a sit-to-stand lift. A Nurse's Note dated 6/18/17, documented the resident had fainted while being transferred in a sit to stand lift to her bed from her chair. The Resident had bruises on her arms and a laceration under her arm where the sling on the sit-to-stand lift had been on the resident. The Accident and Incident Statement dated 6/18/17, from CNA #5, documented she and CNA #6 transferred resident #14 using a stand lift. The Resident passed out in the lift and they lowered her to the floor. The facility Investigation Summary dated 6/19/17, concluded that at the time of the incident, the resident had a bariatric (extra-large) bed that was in the process of being repaired because it was stuck in the lowest position. Both CNAs #5 and #6 stated they knew the resident was a sling lift but utilized the sit to stand lift due to the legs of the mechanical lift not being able to maneuver around the legs of the trapeze (suspended bar overhead that enables the resident to pull themselves up and is anchored by metal legs that run lengthways underneath the bed) with the bed being so low. During an observation and interview on 1/11/2019 at 3:09PM, the Physical Therapy Director, and CNA#7 and #8 were present, demonstrated how the sling lift would be placed under a bariatric bed. She stated the sling lift legs would not fit under the bed when in the lowest position. CNA #7 and CNA #8 demonstrated that unless the bed was up, the legs of the sling lift would not fit under the bed frame. During an observation and interview on 1/11/2019 at 3:40PM, the Director of Nursing (DON), demonstrated how to get the legs of the sling lift under the bariatric bed without hitting the trapeze legs or spring rods and without pulling the bed down. She showed that the lift must go in at an angle. She stated that the CNAs should know how to use the lift. During an interview on 1/10/2019, at 9:30AM, CNA #5 stated that she helped CNA#6 transfer the resident and she passed out. She started to go down and her armpits got caught on the sling. She was lowered to the floor. They noticed she was bleeding under the right armpit, so they called the nurse. During an interview on 1/10/19 at 1:15PM, Registered Nurse #1 (RN#1), stated on 6/18/17, she was the LPN on duty. It happened first thing in the morning, she was called over from another unit. CNAs #5 and #6 told her the resident was a sling lift. They were unable to fit the sling lift under the bed because it was stuck in the lowest position. The bed would not go up so they transferred the resident by using the sit to stand lift. During an interview on 1/11/2019 at 10:43AM, CNA#6, stated the sling lift would not fit under the bed. She and CNA#5 tried to use their best judgement to figure it out, and decided to use the sit to stand lift. The resident went limp and they lowered her to the floor. She was disciplined for not following the care card. 10 NYCRR 415.11(c)(1)

Plan of Correction: ApprovedFebruary 8, 2019

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.

How the corrective action will be accomplished for any resident affected by deficient practice:

Resident # 3 and # 14 are no longer at the facility.
An audit will be completed to ensure that all residents needing supervision for meals are receiving the required supervision.
An audit of all residents requiring mechanical lifts will be done to ensure that staff are not having difficulty using the lifts appropriately.

How we identified other residents/areas that could potentially be affected:

All residents requiring supervision for meals have the potential to be affected.
All residents who use mechanical lifts have the potential to be affected.

Measures to ensure were/will be put into place to assist this area of concern:

The Policy titled Assistance with Meals was reviewed and no revisions were needed.
The Policy titled How to Use a Mechanical Lift was reviewed and no revisions were necessary.
All nursing staff will be re-educated regarding providing the care planned amount of supervision during meals.
All nursing staff will be re-educated on how to properly position mechanical lifts when a low bed is in use.
A list of residents needing 1:1 supervision during meals will be maintained for each unit.

How the concern will be monitored and title of person responsible for monitoring:

10 residents needing 1:1 supervision for meals will be audited weekly x 4, then bi-weekly x 2 and then monthly x 1 to ensure that they are receiving the amount of supervision care planned.
10 residents requiring mechanical lift transfers will be audited weekly x 4, then bi-weekly x 2 and then monthly x 1 to ensure that they are being transferred correctly with the mechanical lift.
Modification, discontinuation or continuation of audits will be based on the QAPI Committee recommendations.

FF11 483.12(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 24, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during abbreviated surveys (Case #s, NY 633, NY 489, NY 364, NY 385, NY 354 and NY 777), the facility did not ensure that all alleged violations involving abuse were reported no later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 8 (Resident #s 3, 4, 5, 6, 7, 8, 9 and 12) of 14 residents reviewed for abuse and neglect. Specifically, the facility did not report allegations of resident-to-resident and staff-to-resident abuse for Resident #s 3, 4, 5, 6, 7, 8, 9 and 12. This is evidenced by: The Policy and Procedure (P&P) titled Abuse/Behavior originated (MONTH) 2012 and updated (MONTH) (YEAR), documented that all alleged violations that involved abuse were to be reported immediately, but no later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. If the event that caused the allegation did not involve abuse and did not result in serious bodily injury, it must be reported no later than 24 hours after the occurrence. Resident #4 Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition, could usually understand others and could usually make herself understood. The facility Investigation Form dated 10/2/18, documented the incident was inappropriate touch and it occurred on 10/1/18. Resident #5 inappropriately touched Resident #4 (the victim). The New York State Department of Health (DOH) Intake Information form documented the alleged event occurred on 10/1/18 at 2:30 AM and the incident was reported to the DOH by the facility on 10/4/18 at 3:55:09 PM. During an interview on 1/11/19 at 8:39 AM, the Housekeeper stated she went into Resident #4's room early in the morning of 10/1/18. She saw Resident #5 standing at the head of the bed. Resident #4 was lying in bed, unclothed from the waist up. Resident #5's brief was pulled down and he was masturbating and caressing Resident #4's breasts. She immediately told staff who responded to the room within about 30 seconds. She remained in the doorway to ensure the residents were safe. Resident #5 had pulled up his brief prior to staff responding but was still caressing Resident #4's breasts. During an interview on 1/11/19 at 2:12 PM, The Director of Nursing (DON) reviewed the Nursing Home Reporting Manual for reporting requirements regarding abuse and neglect, and stated any type of abuse or neglect, needed to be reported to the DOH. If abuse or neglect was alleged, it was supposed to be reported within 2 hours, but no later than 24 hours. This incident should have been reported within 24 hours. Resident #3 Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severely impaired cognition, could usually understand others and could usually make himself understood. The facility investigation form dated 10/23/18, documented the Resident #3 was supposed to have supervision while eating and staff left the resident unattended with his meal on 10/21/18 and subsequently choked on his food. The New York state Department of Health (DOH) Intake Information form documented the alleged event that the CNA did not stay with the resident while he was eating occurred on 10/21/18 at 8:30 AM the incident was reported to the DOH by the facility on 10/25/18 at 6:03 PM. During an interview on 1/11/19 at 9:50 AM, Certified Nursing Assistant (CNA) #1, stated she brought the resident's meal into his room, but did not stay in the room while the resident was eating. During an interview on 1/11/19 at 10:16 AM, LPN #1, stated she saw the resident in the hallway with his hands on his neck. She gave him the [MEDICATION NAME] Maneuver twice and a large, dry piece of pancake was expelled. During an interview on 1/11/19 at 2:12 PM, the Director of Nursing (DON) reviewed the Nursing Home Reporting Manual for reporting requirements regarding abuse and neglect, and stated any type of abuse or neglect, needed to be reported to the DOH. If abuse or neglect were alleged, it must be reported within 2 hours, but no later than 24 hours. Resident #12 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident was usually understood, and was usually understood others. He had severe cognitive impairment. The undated facility Investigation Summary documented the type of incident as an allegation of staff-to-resident abuse that occurred on 1/26/18. The New York State Department of Health (DOH) Intake Information form documented the alleged event occurred on 1/26/18, and the incident was reported to the DOH by the facility on 1/29/18 at 10:25 AM. During an interview on 1/11/19 at 9:15 AM, CNA #3 stated that Resident #12 told her that CNA #4 had slammed him back down into the wheelchair with his hands on the resident's shoulders. During an interview on 1/11/19 at 2:12 PM, The Director of Nursing (DON) reviewed the Nursing Home Reporting Manual for reporting requirements regarding abuse and neglect. Any type of abuse or neglect, needed to be reported to the DOH. If abuse or neglect were alleged, it was supposed to be reported within 2 hours, but no later than 24 hours. 10 NYCRR 415.4(b)(2)

Plan of Correction: ApprovedFebruary 6, 2019

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.

How the corrective action will be accomplished for any resident affected by deficient practice:

Residents # 6, 7, 8 & 9 will have the incidents reported to DOH via HCS.
An audit of all incidents and investigations will be completed to ensure that all others that needed to be reported were reported. Those found not to be will be reported at this time.
The DON will be re-educated regarding the time frames for reporting abuse as written in the NYS Reporting Manual.

How we identified other residents/areas that could potentially be affected:

All residents with incidents requiring reporting to DOH have the potential to be affected.

Measures to ensure were/will be put into place to assist this area of concern:

Policy titled Abuse / Behavior was reviewed and no revisions were necessary.
All Administrative staff will be re-educated regarding the Abuse / Behavior Policy and the NYS Reporting Manual.

How the concern will be monitored and title of person responsible for monitoring:

100% of the incident reports will be audited monthly x 3 to ensure that any requiring submission to DOH have been submitted.
Modification, discontinuation or continuation of audits will be based on the QAPI Committee recommendations.