Bethany Gardens Skilled Living Center
January 24, 2017 Complaint Survey

Standard Health Citations

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification 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: January 24, 2017
Corrected date: March 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the abbreviated survey (NY 707), it was determined for 1 of 3 residents reviewed for abuse/neglect (Resident #1), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown origin were thoroughly investigated, and did not ensure incidents were reported to the New York State Department of Health (NYSDOH) when required. Specifically, the facility did not conduct a thorough and complete investigation when Resident #1 was found to sustain a large bruised area on his chest, and did not report the injury of unknown origin to the NYSDOH as required. Findings include: Resident #1 was admitted to the facility 7/9/2015 with [DIAGNOSES REDACTED]. The undated Resident Care Plan Summary, used by certified nurses aides (CNAs) to provide care to residents, documented the resident was transferred with a Hoyer (mechanical lift) and the assistance of 2 people. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on 2 staff when transferred to and from his bed and wheelchair. Review of the Daily Care Record, used by facility staff to document care provided to residents, revealed no documentation in the section labeled Transfers for the day shifts on 3/11/2016 and 3/12/2016. Evening shift documentation for the same 2 days revealed the resident was not transferred to/from bed, chair. On 3/13/2016, the resident was not transferred to/from bed, chair on the day, evening, and/or night shifts. Review of the resident's Interdisciplinary Progress Notes revealed that on 3/13/2016, a licensed practical nurse (LPN) documented the resident had an ecchymotic (bruised) area to L (left) rib area. The LPN documented the supervisor was made aware & up to assess resident. There was no further documentation of this bruising in the resident's Interdisciplinary Progress Notes. Review of the facility Resident A & I (Accident & Incident) Tracker revealed the following documentation: the resident's name, room number, date (3/13/16), time (10 AM) and shift (1st). The remaining sections - location, RN (registered nurse) assess (assessment) witnessed, origin, ER/hospital, and DOH (Department of Health) - were all blank. There was no documentation available of an Accident/Incident Report and/or facility investigation. There was no documented evidence the resident's family had been notified of the bruising to his left rib cage. When interviewed on 12/14/2016 and 1/24/2017, a family member stated when the family visited the resident on 3/20/2016, he was in bed and wouldn't wake up. The resident's family member unsnapped his gown to feel his chest and noticed a large black and blue area on the resident's left chest and side area. The resident's left upper chest was covered in powder and the bruise covered his upper chest and left shoulder. There was a bruise under his left arm that went to his waist. The family member asked a nurse what happened and never received any explanation. This was the first time any family member was aware of the bruising. When interviewed on 8/10/2016 at 9:00 AM, the Director of Nursing (DON) stated she had been DON since (MONTH) (YEAR). She stated when a resident had any type of unexplained injury, staff assessing the resident should fill out the accident/incident tracker form and complete an incident report. She stated she would look for the tracker form and an incident report for this resident. When interviewed later that day at 3:30 PM, the DON stated there wasn't an Accident/Incident Report anywhere for the resident. When interviewed on 8/10/2016 at 1:00 PM, the Administrator stated the facility had an Accident/Incident tracker form that was a paper log filled out by staff whenever there was an accident, incident, or event involving a resident. She used this form to track trends with resident falls, bruises, and incidents. The Accident/Incident Report was part of this process. Resident #1 was entered on the log by the previous DON; however, the Administrator could not locate an Accident/ Incident Report for the 3/13/2016 bruise. NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedApril 17, 2017



1. Resident # 1 is no longer a resident at this facility.
2. Reviewed policy and procedures to include Accident and Incident, Abuse and Neglect, procedure for skin checks weekly and the purpose, Abuse and neglect policy modified to include immediate suspension of employee until investigation completed.
3. Reviewed current incidents to verify they were investigated and reported timely was completed by the DON for the past 3 months.
4. New hire process in place and an audit of the past three month?s new hires has been completed for Abuse prevention/employee background screening completed, all in compliance.
5. Unable to update care plan, resident is no longer here at the facility.
6. Physical Therapy has been trained in care plans and is currently adding and updating physical function. learning curve in process.
7. All RN's were made aware of the immediate need to assess skin once made aware of concern and full investigation started within 24 hours. LPN's made aware to inform DON or designee.

1. Audit new hires to include registry checks, license is in good standing, reference checks, fingerprinting, date of hire, orientation and fingerprinting complete with each new hire monthly and PRN.
2. Review and investigate origin of bruising and accident and incidents for thorough investigation and reporting within 24 hours by the DON and/or designee.
3. Audit was completed on all residents for verification of current order in place for skin checks weekly by licensed staff. Skin check competencies in process and ongoing.
4. Ongoing daily review of incidents with investigation by the DOn and or designee. IDT discussion daily in am report.

1. All applicable policy and procedures will be reviewed and revised with approval by the Administrator and DON by 3/25/2017. Abuse and Neglect policy was modified to include immediate suspension of employee during investigation.
2. All clinical staff will be in-serviced on skin tears/bruises of unknown origin, proper notification to the DON or designee, care plan violations, reports of abuse, licensed staff skin checks with competencies and expectations by the DON or designee by 3/25/2017.
3. Currently the facility is transitioning from paper kardex to kiosk training and documentation, this will allow more accurate data to staff.
4. MDS will address with Nurse Manager when any discrepancy found.
5. Education - Communication form reviewed with staff to communicate to all disciplines with any concerns, to include: skin issues, bruises, skin tears or any other area of concern on a daily basis. Staff were also made aware to notify the DON or designee of any bruise of unknown origin immediately.
6. Staff re-educated on Accidents and Incidents with discussion of types of incidents that are reportable.


1. The DON has developed an audit tool to ensure abuse prevention and employee screening are done prior to new hire as well as an audit tool to ensure incidents were investigated; residents protected and proper reporting timely.This audit will be done monthly by HR.
2. The DON or designee will complete the Abuse/Investigate/Report audit on a daily, PRN basis to ensure investigations completed and reported when needed.
3. The Director of HR or designee will audit the Abuse prevention/employee background screening prior to the last Monday of each month with new hire orientation.
4. Audits with negative findings will have on site corrective actions implemented, re-training or counseling to direct staff responsible.
5. Audit findings will be reviewed by the Director of HR or designee, DON or designee ongoing and with monthly QA meetings for evaluation and follow up through 3/25/2017, then re-evaluate the frequency of continued audits.
6. Completion date: 3/25/2017 and ongoing if significant overall improvement in compliance is not met.
Responsible Party and Corrective Action Date:
1. Director of Nursing or designee, HR and designee.
2. Expected date of completion 3/25/2017 and ongoing if needed.