M.M. Ewing Continuing Care Center
July 24, 2018 Complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 24, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews conducted during the Abbreviated Survey (complaint #NY 304) completed on [DATE], it was determined that for 10 of 14 residents (Residents #1, #6, #7, #8, #9, #10, #11, #12, #13, and #14) reviewed for abuse, neglect, and mistreatment, the facility did not ensure residents were free from abuse. Specifically, five Certified Nursing Assistants (CNAs) admitted to taking photographs and videos on their cell phones, and some of them were shared via the internet without documented authorization from the resident and/or resident representative. This is evidenced by, but not limited to, the following: The facility policy, Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment, dated [DATE], included that photographing, filming, or recording in any way of patients, visitors, staff or others is prohibited except as described in the policy. In order to preserve the privacy and confidentiality of patients and staff, recordings may only be made for permitted purposes by authorized individuals. Written consent must be obtained from the patient prior to recording any patient image or from the patient's personal representative when the patient is unable to consent. Recordings may never be taken of a patient, or used in any manner, that demeans or humiliates the patient regardless of whether the patient or personal representative consented to the recording. Review of the CNA education records revealed that abuse training was provided to CNA #1 on [DATE], CNA #2 on [DATE], CNA #3 on [DATE], and CNA #4 on [DATE]. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident was rarely or never understood, sometimes understands, and had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative gave permission for the resident to be photographed for social purposes such as films, video tapes, and audio recordings, to be published or broadcast in the Continuing Care Center and/or in the public media. Review of the [DATE] Facility Investigation into unauthorized dissemination of resident photos revealed that CNA #1 admitted to taking and sending a photograph of Resident #1 after he passed away. The copy of the photograph shows the resident's head and part of the chest from the side with a washcloth placed over the mouth area. The resident's eyes are closed and the photograph is captioned he's dead. There is also a copy of a text conversation between CNA #1 and the community member. Review of the [DATE] update report from the Attorney General's office interview with CNA #1 revealed that she admitted to taking and sharing photographs and videos of Residents #7, #8, #9, #10, #11, #12, #13, and #14. When interviewed on [DATE] at 3:05 p.m., the Administrator said that on [DATE] she received a telephone call from a member of the public who reported that CNA #1 had taken a photograph of Resident #1 when he was deceased and had sent it to her. CNA #1 was called and she denied taking the photograph but was suspended pending investigation. When interviewed on [DATE] by the facility, CNA #1 admitted she had taken the photograph because she was upset that the resident had passed away. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNAs #2 and #3 admitted to the Attorney General's office and facility administration that they had received photographs of Resident #12 from CNA #1. On [DATE], CNA #4 admitted to the Attorney General's office and the facility that he had taken a photograph of Resident #12. CNA #4 said he was not sure why he took the photograph. He said that he did not send the photograph to anyone and had deleted it from his cell phone. On [DATE] CNA #3 stated that she believed CNA #1 was taking videos of Resident #12's behaviors. CNA #3 reported that CNA #1 said she needed to send that to CNA #5. On [DATE] in a verbal report from the Attorney General's office to the facility, CNA #1 had admitted to taking five videos of Resident #12 mostly yelling and swearing and sent them to CNA #5. 3. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident has modified independence (difficulty in new situations only) with cognitive skills for daily decision making. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNA #3 admitted to the Attorney General's office and facility administration that she had received several photographs of Resident #11 from CNA #1. She said that everyone on the unit on the evening shift was using their cell phones. Interviews conducted on [DATE] included the following: a. At 9:50 a.m., the Registered Nurse Manager said she was not aware the evening CNAs were using the cell phones to take photographs and videos of residents. She said all staff had been educated on the policy to not take and disseminate photographs previous to these incidents. b. At 12:20 p.m., Resident #4 said she saw staff use their cell phones while they were in her room. She said she was not aware of staff taking photographs or videos but was aware of staff making and receiving phone calls on their cell phones. c. At 12:30 p.m., the family of Resident #5 said they have seen staff using cell phones including in Resident #8's room. She said a male CNA working the evening shift was using his cell phone but she could not tell exactly what he was doing. She said she does not know the CNA's name but knew that he had been terminated. d. At 2:45 p.m., the Director of Nursing (DON) said when she went on rounds on the floors, she did not see staff using cell phones. She said she thinks it was occurring behind closed doors. She said staff are allowed to carry cell phones but not use them. The DON said there have not been any changes made to the policies at that time. e. At 3:05 p.m., the Administrator said that once it was discovered that CNA #1 admitted to taking photographs and videos, several other CNAs were also accused. CNAs #2, #3, #4, and #5 all admitted to taking photographs and videos and distributing many of them to each other and others in the community. The Administrator said staff knew they were doing the wrong thing, and they were hiding what they were doing. The Administrator said the involved CNAs were removed from care and have been terminated. (10 NYCRR 415.4(b))

Plan of Correction: ApprovedAugust 8, 2018

For residents #6, #7, #8, #10, #11, #12, #13 and #14 the Certified Nurses Aides (#1,#2,#3,#4,and #5) involved in not ensuring that residents were free from abuse are no longer employed by M.M.(NAME)Continuing Care Center (MMECCC). CNA #1- was terminated on 07/03/18, CNA #2- was terminated on 7/23/18, CNA #3 was terminated on 07/12/18, CNA #4 was terminated on 07/13/18 and CNA #5 resigned on 07/08/18.
Residents #6, #7, #8, #10, #11, #12, #13 and #14 have been interviewed by Social Work, Director of Nursing (DON) or Nurse Manager (NM) to determine their psychosocial well-being. Residents #6, #7, #8, #10, #11, #12, #13, and #14 have had their care plans reviewed for psychosocial well-being by the Nurse Manager and there was no revisions required. Residents # 1 and #9 are no longer residents of M.M.Ewing Continuing Care Center (MMECCC).
The facility has identified that all residents could potentially be affected by the deficient practice. Change of shift huddles are performed with attention to no cell phone use in resident care areas which includes: Hallways, Nurses Station, Resident Shower, Resident Dining rooms, Resident Rooms, Resident Bathrooms and no taking of photos of anything which includes residents, selfies or still life. Investigation conducted and completed on 07/18/18 by DON, HIPAA compliance officer and NM revealed that no other Residents were affected by the deficient practice at this time.

The DON, Administrator and HIPAA Compliance Officer reviewed facility policy Abuse Prevention Program- MMECCC & Senior Living Services date 09/25/17. The Registered Nurse Educator will provide in service education to all associates who have contact with residents in the CCC utilizing the following resources: Associate Handbook 6.05 Personal Telephone Calls and Electronic devices, Dear Administrator Letter dated 9/27/16, facility policy ?Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment dated 11/6/16 and facility policy Abuse Prevention Program- MMECCC & Senior Living Services date 09/25/17. Abuse education which includes photos and images of Residents occurs at least annually for all Associates. New Associate onboarding now includes an enhanced focus on photography and resident abuse which began on 08/01/2018.
A standardized point of care audit paying attention to cell phone use in resident?s rooms will be completed by the Director of Clinical compliance or her designee every month for 3 months then quarterly. The results will be reported quarterly to the Performance Improvement Committee for action if necessary.
The Plan of Correction will be completed by 9/5/18 and is the responsibility of the Director of Nursing (DON).

FF11 483.10(h)(1)-(3)(i)(ii):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 24, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 304) completed on [DATE], it was determined that for 10 of 14 residents (Residents #1, #6, #7, #8, #9, #10, #11, #12, #13, and #14) reviewed for personal privacy, the facility did not provide care and services to ensure personal privacy was maintained. Specifically, five Certified Nursing Assistants (CNAs) admitted to taking photographs and videos on their cell phones, and some of them were shared via the internet without documented authorization from the resident and/or resident representative. This is evidenced by, but not limited to, the following: The facility policy, Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment, dated [DATE], included that photographing, filming, or recording in any way of patients, visitors, staff or others is prohibited except as described in the policy. In order to preserve the privacy and confidentiality of patients and staff, recordings may only be made for permitted purposes by authorized individuals. Written consent must be obtained from the patient prior to recording any patient image or from the patient's personal representative when the patient is unable to consent. Recordings may never be taken of a patient, or used in any manner, that demeans or humiliates the patient regardless of whether the patient or personal representative consented to the recording. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident was rarely or never understood, sometimes understands, and had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative gave permission for the resident to be photographed for social purposes such as films, video tapes, and audio recordings, to be published or broadcast in the Continuing Care Center and/or in the public media. Review of the [DATE] Facility Investigation into unauthorized dissemination of resident photos revealed that CNA #1 admitted to taking and sending a photograph of Resident #1 after he passed away. The copy of the photograph shows the resident's head and part of the chest from the side with a washcloth placed over the mouth area. The resident's eyes are closed and the photograph is captioned he's dead. There is also a copy of a text conversation between CNA #1 and the community member. Review of the [DATE] update report from the Attorney General's office interview with CNA #1 revealed that she admitted to taking and sharing photographs and videos of Residents #7, #8, #9, #10, #11, #12, #13, and #14. When interviewed on [DATE] at 3:05 p.m., the Administrator said that on [DATE] she received a telephone call from a member of the public who reported that CNA #1 had taken a photograph of Resident #1 when he was deceased and had sent it to her. CNA #1 was called and she denied taking the photograph but was suspended pending investigation. When interviewed on [DATE] by the facility, CNA #1 admitted she had taken the photograph because she was upset that the resident had passed away. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNAs #2 and #3 admitted to the Attorney General's office and facility administration that they had received photographs of Resident #12 from CNA #1. On [DATE], CNA #4 admitted to the Attorney General's office and the facility that he had taken a photograph of Resident #12 CNA #4 said he was not sure why he took the photograph. He said that he did not send the photograph to anyone and had deleted it from his cell phone. On [DATE] CNA #3 stated that she believed CNA #1 was taking videos of Resident #12's behaviors. CNA #3 said that CNA #1 said she needed to send the video to CNA #5. On [DATE] in a verbal report from the Attorney General's office to the facility, CNA #1 had admitted to taking five videos of Resident #12 mostly yelling and swearing and sent them to CNA #5. 3. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident has modified independence (difficulty in new situations only) with cognitive skills for daily decision making. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNA #3 admitted to the Attorney General's office and facility administration that she had received several photographs of Resident #11 from CNA #1. She said that everyone on the unit on the evening shift was using their cell phones. Interviews conducted on [DATE] included the following: a. At 9:50 a.m., the Registered Nurse Manager said she was not aware the evening CNAs were using the cell phones to take photographs and videos of residents. She said all staff had been educated on the policy to not take and disseminate photographs previous to these incidents. b. At 12:20 p.m., Resident #4 said she saw staff use their cell phones while they were in her room. She said she was not aware of staff taking photographs or videos but was aware of staff making and receiving phone calls on their cell phones. c. At 12:30 p.m., the family of Resident #5 said they have seen staff using cell phones including in Resident #8's room. She said a male CNA working the evening shift was using his cell phone but she could not tell exactly what he was doing. She said she does not know the CNA's name but knew that he had been terminated. d. At 2:45 p.m., the Director of Nursing (DON) said when she went on rounds on the floors, she did not see staff using cell phones. She said she thinks it was occurring behind closed doors. She said staff are allowed to carry cell phones but not use them. The DON said there have not been any changes made to the policies at that time. e. At 3:05 p.m., the Administrator said that once it was discovered that CNA #1 admitted to taking photographs and videos, several other CNAs were also accused. CNAs #2, #3, #4, and #5 all admitted to taking photographs and videos and distributing many of them to each other and others in the community. The Administrator said staff knew they were doing the wrong thing, and they were hiding what they were doing. The Administrator said the involved CNAs were removed from care and have been terminated. (10 NYCRR 415.3(d))

Plan of Correction: ApprovedAugust 8, 2018

For residents #1, #6, #7, #8, #9, #10, #11, #12, #13 and #14 the Certified Nurses Aides (CNA) (#1,#2,#3,#4,and #5) who did not ensure Resident personal privacy are no longer employed by M.M.(NAME)Continuing Care Center (MMECCC). CNA #1- was terminated on 07/03/18, CNA #2- was terminated on 7/23/18, CNA #3 was terminated on 07/12/18, CNA #4 was terminated on 07/13/18 and CNA #5 resigned on 07/08/18. Residents and/or the representative for residents #1, #6, #7, #8, #9, #10, #11, #12, #13 and #14 have been notified that their personal privacy was not maintained and that the facility had received information that there was unauthorized dissemination of resident photos. Residents #6, #7, #8, #10, #11, #12, #13 and #14 have had their care plans reviewed with no revisions necessary.
The facility has identified that all residents could potentially be affected by the deficient practice. The Director of Nursing (DON), HIPAA Compliance Officer and the Administrator conducted an investigation and it was determined that no other residents of MMECCC were affected by the deficient practice. Only authorized associates are allowed to take photos of Residents and those associates are aware of how to access the photo release information. CNAs are not authorized to take photos of Residents at MMECCC for any reason.
The Director of Nursing (DON), HIPAA Compliance Officer, and Administrator reviewed facility policy ?Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment dated 11/6/16. The Registered Nurse Educator has provided in service education to all associates who have contact with residents in the MMECCC utilizing the following resources: Associate Handbook 6.05 Personal Telephone Calls and Electronic devices, Dear Administrator Letter dated 9/27/16, facility policy ?Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment dated 11/6/16 and facility policy Abuse Prevention Program- MMECCC & Senior Living Services date 09/25/17. This training occurs annually for all Associates. New Associate onboarding will include an enhanced focus on Photography and resident?s personal privacy beginning 08/01/18.
Using a standard audit tool, the Director of Clinical Compliance or her designee will conduct verbal interviews with Associates regarding their knowledge of the MMECCC Photo taking policy of Residents. The results will be reported quarterly to the Performance Improvement Committee for action if necessary.
A standardized point of care audit paying attention to cell phone use in resident?s rooms will be completed every month for 3 months and then quarterly.
The Plan of Correction will be completed by 9/5/18 and is the responsibility of the Director of Nursing (DON).