The New Jewish Home, Manhattan
April 8, 2019 Complaint Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during an abbreviated survey (NY 392), the facility did not ensure that a resident centered Care Plan (CP) was updated. This was evident for 1 out of 6 residents sampled (Resident #1). Specifically, Resident #1 was at risk for elopement with known history of removing the wander guard. An Elopement CCP initiated on 04/21/2017; updated on 05/03/2018, had no documentation that Resident #1 removed the wander guard multiple times. In addition, there were no interventions in place to address the resident's behavior of removing the wander guard. The findings are: The Facility Policy and Procedure on CCP dated 04/22/2005, stated that the CCP is reviewed and updated at least quarterly and more frequently as warranted by the resident's condition. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 07/20/2018, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 7/15, associated with severe impairment (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Section E of the MDS documented that Resident #1 was assessed with [REDACTED].g., stairs, outside of the facility). Review of the Elopement/Wandering Note dated 04/21/2017, revealed that Resident #1 was assessed for elopement risk and scored 13. Per Elopement Risk document, if score is 7 or greater, the resident is considered high risk - complete Elopement Unsafe Wanderer Care Plan. Review of the Risk for Elopement Care Plan initiated on 04/21/2017, revealed that Resident #1 was at risk for elopement. The interventions included wander guard applied due to observed behavior of unsafe wandering towards exit doors and elevators. Staff to monitor due to high risk for elopement. Review of the Wander Guard Sensor Notification document dated 05/10/2017, revealed that Resident #1 had his Wander Guard replaced. Review of Resident #1's CCP dated 04/21/2017, revealed that there were no updated CCP with documentation or interventions to reflect on the removal and replacement of the Wander Guard. Review of the Wander Guard Sensor Notification document dated 05/20/2018, revealed that Resident #1 had his Wander Guard replaced by the Security Guard. There were no updated CCP with documentation or interventions to reflect on the removal and replacement of the Wander Guard. Security Guard's Supervisor was interviewed on 08/31/2018 at 3:02 PM and stated that Resident #1 took his Wander Guard off multiple times and that the nursing staff requested replacement Wander Guards at least three times. A follow up interview was conducted with the Assistant Director of Nursing (ADON) on 02/21/2019 at 3:55 PM. She stated that any changes with the resident's condition or any issues regarding the resident's safety, the Registered Nurse or Nursing Supervisor updates the care plan and that the CCP should have been updated. 415.11(c)(2) (i-iii)

Plan of Correction: ApprovedApril 26, 2019

Plan for Affected Resident
The interdisciplinary team met, including the health care proxy and confirmed that the plan of care addressed all identified needs. 8/7/2018
Plan for Potentially Affected Residents
The interdisciplinary team re-assessed all the residents in the facility for their risk for elopement. 7/24/2018
The care plans for all of the residents at risk for elopement were reviewed by the interdisciplinary team and it was confirmed that the plan of care addressed the identified needs of residents at risk for elopement. 7/24/2018
Measures and Systems
The Director of Nursing reviewed the existing policy for Comprehensive Care Planning and confirmed that it meets all of the regulatory requirements for the development of an individualized comprehensive plan of care. 4/26/2019
The Director of Nursing/designee will re-inservice all appropriate clinical staff on the existing policy. 6/1/2019
Monitoring
On a monthly basis for the next three months the Director of Nursing/designee will audit 100% of the care plans of those residents at risk for elopement to confirm that the plan of care is updated to reflect any changes. 6/1/2019
The results of these audits will be presented at the monthly QAPI committee meeting. At the conclusion of three months, the QAPI committee will make recommendations for ongoing audits.
The Director of Nursing will be responsible for maintaining compliance

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during an abbreviated survey (NY 392), the facility staff did not respond appropriately to multiple alarmed exit doors, to prevent a resident from eloping the facility. This was evident for 1 out of 6 residents sampled (Resident #1). Specifically, on 07/22/2018, Resident #1 activated the alarmed exit doors in the facility's three adjoining buildings (building 1, building 2, and building 3). Facility staff in building 2 and building 3 disabled the alarms without having searched the stairwells. The resident exited the facility by navigating his way through the three buildings undetected by staff. The Facility Policy on Missing/Wandering Residents dated 05/19/2017, revealed under title Wander Management System, Procedure for operation of Wander Management System: C. respond to area activated, check area and act accordingly. D. Notify Nursing/Day Care that system was activated. E. Log information at Reception Desk. Reset System (code noted) and acknowledge the alarm. The facility policy on Safety & Security: Alarms effective 06/17/2014 documented that the computerized security system is equipped with an audio and visual alarm. The numbered visual alarm will blink on and off and the audio alarm will sound when any of the doors wired to this system are compromised. A security officer shall be dispatched immediately to the area of the compromised alarm. The computerized security system is located at the Main Entrance security desk. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 07/20/2018, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 7/15, associated with severe impairment (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Resident #1 required supervision with walking in corridor; locomotion on and off the unit. Section E of the MDS documented that Resident #1 was assessed with [REDACTED].g., stairs, outside of the facility). An Elopement Risk assessment dated [DATE] documented that Resident #1 was assessed and scored 13 points, denoting high risk for elopement. A Risk for Elopement Care Plan initiated on 04/21/2017, revealed that Resident #1 was at risk for elopement. The interventions included wander guard applied due to observed unsafe wandering behavior towards exit door and elevator. Staff to monitor due to high risk for elopement. A Resident Care Summary dated 01/19/2018 documented that Resident #1 was on visual check every hour for elopement risk and wander guard to his right ankle. The Nursing Note dated 07/22/2018, by RNS #2, documented that he was notified at approximately 11:52 AM by RNS #1 that staff was unable to visually confirm resident ' s whereabouts and a Silver Alert search commenced. 911 was notified and assisted in coordinating the search. Notification received that resident had been visually seen off premises and was sent to the emergency room (ER) for full clinical assessment to rule out any changes or injuries. The Nursing Note dated 07/22/2018, by LPN #1, documented that the resident was seen sitting in the hallway at 11 AM while the CNA was making rounds. LPN #1 was with a resident in the bathroom when she heard the door alarm and ran to the door immediately and down the stairs but did not see anyone. She returned to the unit and asked the CNAs to check if any resident was missing. They realized that Resident #1 was missing and informed the Supervisor and security. They all searched until they were informed that the resident had been located. Surveyor #1, together with Security Supervisor and the Associate Director of Nursing (ADON), viewed the recorded video of buildings and floor locations on 08/29/2018 at 1:30 PM. The times shown on these video recordings were actual, but some of the recordings from different cameras were between 8 to 10-minutes delayed recordings as per the ADON. Resident #1 was observed on 07/22/2018 at 11:22 AM, in building 1 on the 6th floor (FL). The resident was wearing eye glasses, a long-sleeved red shirt, beige pants, slippers and was carrying a newspaper in his left hand. Building 1, 6th FL Door to Stairway H Camera, (Cam) with 10 minutes delayed time, revealed that on 07/22/2018 at 11:12 AM (actual time 11:22 AM), Cam showed Resident #1 wandering the hallway and exited the door leading to Stairway H. On 07/22/2018 at 11:14 AM (actual time 11:24 AM) Cam showed Licensed Practical Nurse #1 (LPN #1) exiting the same door leading to Stairway H. On 07/22/2018 at 11:15 AM (actual time 11:25 AM), Cam showed LPN #1 returned from the same door at Stairway H. On 07/22/2018 at 11:17 AM (actual time 11:27 AM), Cam showed Certified Nurse Aide #1 (CNA #1) exited the same door leading to Stairway H. Building 2, 2nd FL Cam showed that on 07/22/2018 at 11:40 AM (actual time), CNA #3 opened the exit door leading to stairway H. CNA #3 was observed pressing button pads to disable the alarm. Around this same time, the Cam showed Resident #1 walking the corridor, after coming out from room [ROOM NUMBER]. No interaction between CNA #3 and the Resident was observed. Building 3, 2nd FL Cam showed that on 07/22/2018 at 11:42 AM (actual time), Resident #1 entered through a connecting doorway, entering building 3 from building 2. Resident #1 was observed walking the corridors of building 3. On 07/22/2018 at 11:44 AM, Cam showed Resident #1 opened an alarmed exit door leading to stairwell M. On 07/22/2018 at 11:53 AM, Cam showed CNA #5 opened the same exit door leading to the stairwell that Resident # 1 exited from. CNA #5 was observed disabling the alarm, by pressing the key pads, without having searched the stairwell. Building 3, door #28 (leading to the street) Cam with 8 minutes delay: On 07/22/2018 at 11:40 AM (actual time 11:48 AM) Cam showed Resident #1 exited through door #28, leading to the street. An Elopement / Unsafe Wanderer Monitoring Log dated 07/22/2018, prior to incident, noted that Resident #1 was being monitored every 2 hours. The form showed that at 1:00 PM and 3:00 PM, the letters PU (Auditorium - code used to identify a resident's whereabouts) written in the boxes, which would indicate that Resident #1 was in the facility's Auditorium at those time. The letters DR (Dining Room) was documented in the 5:00 PM box, which indicated that Resident #1 was in the DR at 5:00 PM. However, someone wrote over the letters PU and DR at 1:00 PM, 3:00 PM and 5:00 PM to indicate that the resident was out of the facility. CNA #4, worked in building 2, was interviewed on 09/07/2018 at 2:58 PM and stated that the incident occurred on a Sunday and that a lot of family members utilized the stairs to building 2; kept triggering the alarm and she went back/forth disabling the alarm. There was one instance when she disabled the alarm. She observed someone coming out of a room and thought it was a family member because the person was neatly dressed and was carrying a newspaper. When the Supervisor showed her a photo of the Resident missing resident, she realized that the person she thought was a family, was a resident. She stated that she participated in the search for Resident #1. CNA #5, who worked in building 3, was interviewed 09/04/2018 at 1:29PM and stated that on the day of the incident, she heard the alarm, went to the door and did not see anyone, so she disabled the alarm. She did not hear the code for missing resident and she knew the whereabouts of all her residents. When she did hear the missing resident code, she checked all the rooms and stairwells. The Director of Nursing Service (DNS) was interviewed on 03/13/2019 at 10:00 AM and stated that when an exit door alarm is triggered on the unit, staff should open the door; check up/down the stairwell to ascertain if someone went out, ensure all residents are accounted for before disabling the alarm. Staff required to notify the Security Guard that an alarm was activated so Security can check. Upon inquiry, the DNS stated that any staff can disable the alarm by pushing a button, no code is required to disable the alarm. 415.12 (h)(1)

Plan of Correction: ApprovedApril 26, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Plan for Affected Resident
The affected resident was assessed upon return to the facility by the RN nursing supervisor with noted normal vital signs, no visible injuries and no change in mental status. The placement of the wanderguard was confirmed and he was placed on 15 minute checks. 7/22/2018
An interdisciplinary care plan meeting took place to confirm that all identified needs were addressed. 8/7/2018
The two identified staff members not appropriately responding to the stairwell door alarms were disciplined and provided with additional education on responsibilities related to responding to stairwell door alarms. 9/3/2018
Plan for Potentially Affected Residents
The Director of Nursing determined that all residents at risk for elopement had the potential to be affected therefore all residents at risk for elopement were re-assessed with [REDACTED].
Measures and Systems
The Director of Support Services reviewed the existing policy for Alarms and revised it to include the specific responsibilities delineated for all staff responding to stairwell door alarms. 4/26/2019
The Clinical Educator will provide education to all staff on the revised policy 6/1/2019
Monitoring
On a weekly basis for the next three months, the Assistant Administrator/designee will conduct random audits of staff response to stairwell door alarms. 6/1/2019
The results of these audits will be presented at the monthly Environment of Care meeting. At the end of three months, the committee will make a recommendation for ongoing auditing.
The Director of Nursing will be responsible for maintaining compliance

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 8, 2019
Corrected date: June 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during an abbreviated survey (NY 392), the facility did not ensure that an Elopement Incident was thoroughly investigated. This was evident for 1 out of 6 residents sampled (Resident #1). Specifically, on 07/22/2018, Resident #1 activated the exit door alarms in the facility's three adjoining buildings (building 1, building 2, and building 3). Facility staff in building 2 and building 3 disabled the alarms without having searched the stairwells. The facility's investigation did not address the cause of the activated alarms in buildings 2 and 3, through which Resident #1 exited the facility. Therefore, facility's conclusion did not accurately reflect the complete factors involved in the elopement occurrence. The Facility Policy on Accident Investigation dated 12/2014, revealed that resident accidents must be investigated in a thorough and timely manner. The Assistant Director of Nursing or Designee must review all accident investigation to ensure that the investigation has been thorough and that corrective actions taken are appropriate to minimize re-occurrence of accident or injury. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 07/20/2018, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 7/15, associated with severe impairment (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Resident #1 required supervision with walking in corridor; locomotion on and off the unit. Section E of the MDS documented that Resident #1 was assessed with [REDACTED].g., stairs, outside of the facility). Surveyor #1, together with Security Supervisor and the Associate Director of Nursing (ADON), viewed the recorded video of buildings and floor locations on 08/29/2018 at 1:30 PM. The times shown on these video recordings were actual, but some of the recordings from different cameras were between 8 to 10-minutes delayed recordings as per the ADON. Resident #1 was observed on 07/22/2018 at 11:22 AM, in building 1 on the 6th floor (FL). The resident was wearing eye glasses, a long-sleeved red shirt, beige pants, slippers and was carrying a newspaper in his left hand. Building 1, 6th FL Door to Stairway H Camera, (Cam) with 10 minutes delayed time, revealed that on 07/22/2018 at 11:12 AM (actual time 11:22 AM), Cam showed Resident #1 wandering the hallway and exited the door leading to Stairway H. On 07/22/2018 at 11:14 AM (actual time 11:24 AM) Cam showed Licensed Practical Nurse #1 (LPN #1) exiting the same door leading to Stairway H. On 07/22/2018 at 11:15 AM (actual time 11:25 AM) Cam showed LPN #1 returned from the same door at Stairway H. On 07/22/2018 at 11:17 AM (actual time 11:27 AM) cam showed Certified Nurse Aide #1 (CNA #1) exited the same door leading to Stairway H. Building 2, 2nd FL Cam showed that on 07/22/2018 at 11:40 AM (actual time), CNA #3 opened the exit door leading to stairway H. CNA #3 was observed pressing button pads to disable the alarm. Around this same time, the Cam showed Resident #1 walking the corridor, after coming out from room [ROOM NUMBER]. No interaction between CNA #3 and the Resident was observed. Building 3, 2nd FL Cam showed that on 07/22/2018 at 11:42 AM (actual time), Resident #1 entered through a connecting doorway, entering building 3 from Building 2. Resident #1 was observed walking the corridors of building 3. On 07/22/2018 at 11:44 AM, Cam showed Resident #1 opening an alarmed exit door leading to the stairwell M. On 07/22/2018 at 11:53 AM, Cam showed CNA # 5 opening the same exit door leading to the stairwell that Resident # 1 exited from. CNA #5 was observed disabling the alarm, by pressing the key pads, without having searched the stairwell. Building 3, door #28 (leading to the street) Cam with 8 minutes delay: On 07/22/2018 at 11:40 AM (actual time 11:48 AM) Cam showed Resident #1 exited through door #28, leading to the street. Review of the Accident/Incident (A/I) Investigation dated 07/22/2018, revealed that an exit door alarm went off and LPN #1 checked to see if anyone was there and when she did not see anyone she went back to the unit and conducted a head count. After finding out that Resident #1 was missing security was notified. The staff on duty on building 1, 6th FL, followed the plan of care and responded accordingly. The facility's investigation concluded that Resident #1's wander guard was not working well. The facility's investigation did not address how Resident #1 navigated buildings 2 and 3 without staff's knowledge. In addition, the investigation did not include statements from CNA #4 and CNA #5, who disabled the alarms in buildings 2 and 3, without having searched the stairwells. The Assistant Director of Nursing (ADON) was interviewed on 09/04/2018 at 1:40 PM and stated that she watched the recorded video on a small monitor and that she did not see CNA #4 and CNA #5, disabled the alarms in building 2 and 3. Her focus was only on Building 1, 6th Floor. A follow up interview was conducted with the ADON on 02/21/2019 at 3:55 PM, and she stated that she has been reviewing the A/I's and that she is still in charge of facilitating investigations. Once the facility became aware that the Elopement was not thoroughly investigated, the policy on Elopement was immediately reviewed. 415.4(b)(ii)

Plan of Correction: ApprovedApril 26, 2019

Plan for Affected Resident
The affected resident was assessed upon return to the facility by the RN nursing supervisor with noted normal vital signs, no visible injuries and no change in mental status. The placement of the wanderguard was confirmed and he was placed on 15 minute checks. 7/22/2018
An interdisciplinary care plan meeting took place to confirm that all identified needs were addressed. 8/7/2018
An addendum to the investigation was added on 9/3/2018 to include a review of the CCTV and identification of the individual staff members who disabled the stairwell door alarms without searching the stairwells.
The two identified staff members not appropriately responding to the stairwell door alarms were disciplined and provided with additional education on responsibilities related to responding to stairwell door alarms. 9/3/2018
Plan for Potentially Affected Residents
The Assistant Director of Nursing reviewed the DOH reported incidents from the past six months to confirm that all investigations were complete. 4/26/2019
Measures and Systems
The Administrator reviewed the existing policy for Incident Investigation and revised it to include, when available, the inclusion of CCTV review in the investigation. 4/26/2019
The Director of Support Services reviewed the existing policy for Alarms and revised it to include the specific responsibilities delineated for responding to stairwell door alarms. 4/26/2019
The Director of Nursing/designee will provide education to all of the nursing administrative staff on the revised policy for Incident Investigations. 6/1/2019
The Director of Support Services and Clinical Educator will provide education to all clinical staff on the revision to the Alarm policy and responsibilities related to responding to stairwell door alarms. 6/1/2019
Monitoring
On a monthly basis for the next three months the Administrator will audit 100% of all reportable incidents to confirm that the investigation is complete 6/8/2019
The results of the audit will be presented at the facility?s monthly QAPI committee meeting. After a period of three months the committee will recommend frequency of auditing
On a monthly basis for the next three months, during weekly Environment of Care Rounds the team will conduct an audit of response to stairwell door alarms. 6/8/2019
The results of these audits will be presented at the monthly Environment of Care meeting.
The Director of Nursing will be responsible for maintaining compliance