Promenade Rehabilitation and Health Care Center
April 24, 2018 Complaint Survey

Standard Health Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2018
Corrected date: May 31, 2018

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 075, NY 082) the facility did not ensure that investigation results of all alleged violations involving abuse are reported within a timely manner to the New York State Department of Health (NYSDOH). This was evident in 4 out of 6 residents sampled (Residents #1, #2, #3, & #4). Specifically, the facility received a report on 12/1/2017 and 12/15/2017 on an alleged resident to resident abuse. The facility reported both allegations to the NYSDOH on 2/12/2018, 2 months after the incidents occurred. The findings include: The facility Policy and Procedure with a subject Abuse Investigation with a revised date of 12/01/2016 stated that all reports of resident abuse shall be promptly and thoroughly investigated by facility management. The policy also stated that the facility must report results of the investigation to the Administrator and to other officials in accordance with state law including to the State Survey Agency, within 5 working days of the incident. Resident #1 is a [AGE] year-old male who was initially admitted to the facility on ,[DATE]//2012. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 09/21/2017 showed that Resident #1 had a BIMS (Brief Interview for Mental Status used to determine attention, orientation, and ability to recall information) score of 0 out of 15, indicating severe impairment in cognition (00-07 Severe Impairment, 08-12 Moderate Impairment & 13-15 Cognitively Intact). Resident #2 is [AGE] year-old male who was initially admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS dated [DATE] showed a BIMS score of 11 out of 15 indicating moderate impairment in cognition. Resident #3 is a [AGE] year-old female who was initially admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS dated [DATE] showed a BIMS score of 0 out of 15 indicating severe impairment in cognition. Resident #4 is a [AGE] year-old-female who was initially admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS dated [DATE]showed a BIMS score of 14 out of 15 indicating cognitively intact in cognition. The facility Resident Accident/Incident Report dated 12/1/2017 documented that on 12/01/2017 at 4:30PM Resident #2 claimed he was hit in the head by Resident #1. The physician findings documented Incident as noted above, no change in vision at this time. He does have tenderness to orbit of left eye. No swelling or bruises noted. Further review of the accident/incident report showed that it was not signed by the Administrator. The facility Resident Accident/Incident Report dated12/15/2017 documented that on 12/15/2017 at 10:15AM Resident #4 reported that she was kicked by Resident #3 in her groin. The physician findings documented there was no visible injury noted. Further review of the accident/incident report showed that it was not signed by the DNS (Director of Nursing Service)/ADNS and the Administrator. Resident #3 was transferred to the hospital where she was admitted for aggressive physical behavior. The resident was readmitted to the facility and was assigned to a different unit. The summary of investigation was signed by the ADNS on 2/5/2018. During an interview with the ADNS on 04/05/2018 at 02:58 pm, she stated that she is responsible for investigating and reporting all alleged incidents of resident abuse within 5 working days to the NYSDOH. According to the ADNS she investigated and wrote the summary for the 12/01/2017 and 12/15/2017 alleged incidents. She stated that while they were doing Quality Assurance review they discovered that the incidents were not reported to the NYSDOH. The ADNS also stated that the 12/01/2017 and 12/15/2017 incidents were overlooked and they (with the Administrator and the DNS) decided to report it although it was late than never. She stated that she does not know why the incident reports were not signed by the Administrator. During an interview with the Administrator on 04/24/2018 at 4:00 pm, he stated that all incidents regarding resident abuse must be reported to the NYSDOH within 5 working days. The Administrator stated that he does not remember why the incident was not reported to NYSDOH within 5 working days. He further stated that during the Quality Assurance meeting they realized that the incident must be reported to DOH. He added that it is better to report later than never. During an interview with the DNS on 04/05/18 at 3:47 pm, she stated that all incidents must be thoroughly investigated immediately. She stated that all incidents involving resident abuse must be reported to the NYSDOH within 5 working days. The DNS stated that it is the ADNS's responsibility to investigate and report the alleged incidents to the NYSDOH. The DNS stated that she oversees the ADNS but on the alleged incident dates she was not sure if she was in the facility because she comes to work on and off. She stated that when she is not around it is the Administrator who oversees the ADNS. The DNS stated that she cannot answer why the 12/1/2017 and 12/15/2017 alleged incidents were reported late to the NYSDOH. 415.4(b)

Plan of Correction: ApprovedMay 16, 2018

F609
I. Immediate Corrections:
1. a.The Administrator, DNS & ADNS reviewed the Policy & Procedure for Accident investigations Policy relative to timely reporting to the DOH
b. A copy of the review was retained for validation.
2.The Accident report for the resident to resident altercations involving Resident #1 & 2, and residents #3 &4 were reviewed by the DNS at the quarterly Risk Management QA. Subsequently it was noted that the reports were not called into the DOH and therefore, the DOH was notified as per requirements.
2.The Administrator has reviewed the Accident reports for the resident to resident altercation between Res #3 and Res #4 and subsequently signed and dated the report.
3. The DNS respectfully states that she is the fulltime DNS and reviews all Accident reports as they are brought to her attention. The ADNS reviewed the Accident report for res #3 &4 relative to the altercation and signed and dated the report.
II. Identification of Other Residents
1. The DNS has reviewed all Accident reports for the last quarter to ascertain if the reports were appropriately signed and reported if needed.
2. There were no quality issues identified from this review.
III. Systemic Changes:
1. The DNS reviewed the Policy for Accident investigations with a concentration on the reporting criteria and found same to be compliant. The DNS/ADNS and Administrator will continue to review all Accidents as per policy to ensure timely DOH notification if indicated.
2.a. The DNS has made a new directive that any Accident report generated will be brought to the morning report for a QA review to track the investigative process to ensure the completeness of the investigation, appropriate signage and to evaluate whether same needs to be reported.
b. All morning report discussions and follow up are documented on the Morning Report sheet, as well as attendance; and same will now include the ongoing review of any Accidents or Incidents for validation.
3. The ADNS, Administrator and all Licensed Nurses will be informed of this directive by the DNS. A sign in attendance sheet will validate this education.
IV. QA Monitoring:
A.1.The DNS has developed an audit tool to track the completeness odf Accident Investigations and follow up as per policy and requirements.
2. Audits will be completed by the ADNS at the Morning meeting to validate the tracking and QA review of reports discussed.
3. Any quality issues identified by the audits will have onsite correction by the AND and/or the DNS.
4. Audits will be presented at the quarterly QA Meetings for follow up as indicated.
B. 1. The DNS has created a Log to document all Accident reports that have been called in to the DOH. The log will include the resident information, the date of the Accident and the date of notification to DOH. Any correspondence received by the DOH ie reference # will also be added to the log. The Log will be maintained with all risk management documents and discussed at QA Meetings for follow up.
2. The completion of the Log will be done by the ADNS and reviewed by the DNS and Administrator for ongoing compliance with policy and requirements. The DNS has inserviced the ADNS on the documentation criteria for the Log.