Hornell Gardens, LLC
March 21, 2017 Complaint Survey

Standard Health Citations

FF10 483.10(e)(1), 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). 42 CFR §483.12, 483.12(a)(2) 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 symptoms. (a) The facility must- (1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident?s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2017
Corrected date: April 11, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 580) completed on 3/21/17, it was determined that for one (Resident #1) of three residents reviewed for potential abuse, neglect, and mistreatment, the facility did not complete a comprehensive assessment to evaluate the appropriateness and safety of the physical restraint. The issue involved a lack of an assessment for the use of two gait belts to restrain a resident in a wheelchair. This is evidenced by the following: Resident #1 has [DIAGNOSES REDACTED]. The facility Investigation Summary, signed by the Director of Nursing (DON) on 3/10/17, documented that on 2/26/17 at approximately 5:30 a.m., an incident was reported to Registered Nurse (RN) #1 involving the use of a gait belt to restrain the resident on 2/25/17 at 12:00 p.m. When interviewed on 3/2/17 at 9:00 a.m., the Administrator stated that on 2/25/17 the resident was agitated, and up and down in his wheelchair, when Licensed Practical Nurse (LPN) #2 decided to use a gait belt around the resident's wheelchair to prevent further falls. The Administrator said that LPN #2 convinced Housekeeper #2 to obtain a second gait belt to put around the resident because one gait belt did not reach all the way around to the back of the wheelchair. The Administrator stated that the gait belts were secured around the resident in his wheelchair for less than an hour and then removed. Interviews conducted on 3/7/17 included the following: a. At 9:30 a.m., LPN #1 stated that on 2/25/17, the resident had fallen five times during the day shift. LPN #1 stated that around lunch time she saw the resident at the nurses' station with two gait belts snapped together in front of him and tied on both ends in the back, on the bottom of the wheelchair. LPN #1 stated that the resident was more agitated, grabbing and trying to grab other residents' silverware while trying to get the gait belts off. LPN #1 stated that the resident was restricted, but it was not tight. LPN #1 added that the gait belts were on the resident for approximately a half hour. LPN #1 stated she knows that she should have removed the gait belts, but she was more scared that LPN #2 would reapply them. She said LPN #2 was in charge and you do not go over charge nurses. b. At 10:40 a.m., Housekeeper #1 stated that on 2/25/17, when she went to stock linen on the resident's unit, the resident asked her for a knife or scissors. She said the resident was pulling at the gait belt and stated he wanted to cut it off. Housekeeper #1 said the resident was sitting in a wheelchair in front of the nurses' station and the gait belts were tied around the wheelchair. Housekeeper #1 said that the next day, she asked another staff member how the resident was doing because he was so upset and irritated the day before and wanted to cut the gait belts off. Housekeeper #1 stated that she did not know how long the resident was tied to his wheelchair, but it was possibly 1 1/2 hours or less. c. At 2:30 p.m. by telephone, RN #1 stated that on 2/26/17 at 5:30 a.m., she received a text from a staff member advising her that Housekeeper #1 reported that the resident was restrained to his wheelchair with gait belts on 2/25/17. RN #1 said that she went to the facility at 6:15 a.m., and was told that Housekeeper #2 was also involved in restraining the resident. RN #1 stated that she was not on-call, but she is the back up on-call RN. She said she was not notified on 2/25/17 of the resident's falls, behaviors, or use of restraints. d. At 2:45 p.m., RN #2 stated that she was the on-call RN on 2/25/17 and did not receive any calls related to the resident's falls, behaviors, or use of restraints. Interviews conducted on 3/10/17 included the following: a. At 10:10 a.m., LPN #2 stated that on 2/25/17, she saw the gait belt around the resident when he was sitting by the nurses' station after lunch. LPN #2 said she does not know who applied the gait belts or how it was secured. She assumed the gait belts were hooked on the back of his wheelchair. LPN #2 said that the resident was anxious and asked for scissors or a knife to remove the gait belts. LPN #2 said she asked staff to put the resident to bed. LPN #2 stated that she did not know that a physician order [REDACTED]. She said she had abuse training but was not sure if there was anything about restraints included. LPN #2 added that there was an RN on call, but the RN was not contacted about the resident's falls or behaviors because he was not hurt. b. At 11:10 a.m., Certified Nursing Assistant (CNA) #1 stated that on 2/25/17, she was assigned to care for the resident and he had several falls that morning. CNA #1 stated that, around lunchtime, she saw gait belts around the resident that were clipped around the back of his wheelchair. CNA #1 stated that the gait belts were around the resident's arms and belly, with his arms under the gait belts. CNA #1 said that the resident wanted her to remove the gait belts. CNA #1 said when she started to remove them, one of the nurses said, Do not remove them, they are there for a reason. CNA #1 stated the way the gait belts were applied, the resident would not have been able to stand up. CNA #1 stated that she knew something was wrong and planned to call RN #1 or the DON to tell them but did not have their telephone numbers. CNA #1 stated that LPNs #1 and #2 were talking about the gait belts being on the resident for safety reasons. CNA #1 stated that the gait belts were around the resident for about an hour, and she knew from her abuse training that this was unacceptable. She said the nurses knew what was going on and brushed it off. c. At 12:50 p.m., Housekeeper #2 stated that on 2/25/17, in the early afternoon, the resident had a gait belt around the front of him, laying there unhooked. Housekeeper #2 stated that LPN #2 asked him to get another gait belt to attach it to the other one because the gait belt was not long enough to reach around to the back of the wheelchair. Housekeeper #2 stated that he snapped the second gait belt together and the gait belt went around the wheelchair like a circle. Housekeeper #2 stated that the resident got angry and wanted people to cut the gait belt off. Housekeeper #2 stated that he told LPN #2 that he did not mind doing it for the resident's safety, but she should get a hold of someone like a doctor to come in and evaluate the resident because he was not himself. Housekeeper #2 stated that LPN #2 did not seem to know who to contact. Housekeeper #2 stated that he and LPN #1 agreed that they needed to contact the Nurse Manager or RN #1 for direction, but he was not sure what was done. d. At 3:15 p.m., the DON stated that staff did not notify the on-call RNs about the resident's falls, behaviors, or application of the gait belts to restrain the resident until 2/26/17 when RN #1 was in the facility. The undated facility policy, Abuse, Neglect and Mistreatment Prohibition, Investigation, and Reporting, identified mistreatment as the inappropriate use of medications, inappropriate isolation or inappropriate use of physical or chemical restraints on a resident of a residential health care facility while the resident is under the supervision of the facility. The undated facility policy, Restraint Guideline, revealed that a physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. A physical restraint is used only to protect the health and safety of the resident and/or to assist the resident to attain and maintain optimum levels of physical and emotional functioning, and use of a physical restraint is to be an integral part of the interdisciplinary care plan. (10 NYCRR 415.4(a)(2-7))

Plan of Correction: ApprovedApril 6, 2017

The preparation and execution of this plan of correction does not constitute admission or agreement with the facts alleged or conclusions set forth in this statement of deficiencies. This plan of correction is executed solely because it is required by Federal law.
1. The LPN removed the gait belts from resident #1 on 2/25/17. The RN on call ensured that resident #1 was without physical restraint and assessed his overall condition on 2/26/17. The LPN who placed the gait belt on resident #1 was counseled on 2/26/17 and is no longer employed by the facility.
2. The IDT members have reviewed all residents who use potential physical restraints to ensure appropriateness of each device on 3/8/17.
3. The Use of Restraint Policy was reviewed by the Director of Nursing, Social Worker and Administrator on 2/27/17. The Staff development Coordinator will inservice Nursing staff on the Restraint Use Policy by 4/11/17.
4. All residents using physical restraint devices will be audited by the Nurse Managers or their designee weekly for four weeks then monthly and then intermittently as determined by the QA Committee to ensure that the use of the devices are necessary. The results of these audits will be provided to the QA Committee for their review and action as necessary.
The Nurse Managers will be responsible for the correction of this deficiency

FF10 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2017
Corrected date: April 11, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 580) completed on 3/21/17, it was determined that for two (Residents #1 and #2) of three residents reviewed for professional standards, the facility did not provide services that met the professional standard of quality. The issue involved the lack of a Registered Nurse (RN) or physician's assessment prior to moving a resident after a fall. This is evidenced by the following: 1. Resident #1 has [DIAGNOSES REDACTED]. The Certified Nursing Assistant (CNA) Care Plan, revised 2/15/17, included at risk for falls, two assist with wheeled walker and stand pivot for transfers. Review of the Incident and Accident (I/A) Reports of 2/26/17 revealed the following: a. LPN #3 documented that on 2/25/17 at 9:00 a.m., the resident was found on his knees next to his bed, yelling. The resident was directed to lift his legs and get back into bed, which he did. b. LPN #3 documented that on 2/25/17 at 9:30 a.m., the resident was on the floor on his knees, leaning on his elbows. The resident was assisted back into bed with direction. c. LPN #1 documented that on 2/25/17 at 12:00 p.m., the resident was found on the floor in the day room. Staff tried to get the resident to pull himself up, but the resident was unable to help, and was placed back into his wheelchair. Review of the Integrated Progress Notes revealed no RN or physician assessment. Interviews conducted on 3/7/17 included the following: a. At 9:30 a.m., LPN #1 stated that on 2/25/17, the resident had fallen three times that morning. LPN #1 stated that after the resident's third fall, he scooted himself to the bathroom and used the door handle with LPN #3's and her assistance to help him to his feet. LPN #1 said that the resident had fallen two more times on 2/25/17 and the RN was not notified. LPN #1 said that the two on-call RNs are often unavailable. b. At 2:30 p.m., RN #1 stated that when a resident falls the expectation is that the LPN notifies the on-call RN, and the RN either comes to the facility or provides direction based on the LPN's observations. RN #1 stated that an RN directs the LPN if the resident can be removed from the floor. RN #1 said she was the back-up RN on-call on 2/25/17 and she did not receive any calls related to the resident's falls. c. At 2:45 p.m., RN #2 stated that she was the on-call RN on 2/25/17 and received no calls about the resident's falls that day. RN #2 said that if she is on call on Sundays, she is not available from 11:00 a.m. - 1:00 p.m., and staff have to wait until she returns their calls. RN #2 said that LPNs can remove residents from the floor without RN notification or assessment. Interviews conducted on 3/10/17 included the following: a. At 10:10 a.m., LPN #2 stated that on 2/25/17, when the resident fell in the day room, she and LPN #1 assessed the resident. LPN #2 said that the on-call RN was not called because the resident was not hurt. b. At 1:55 p.m., LPN #3 stated that on 2/25/17 between 9:00 a.m. and 9:30 a.m., the resident rolled out of bed onto his knees on the floor. She said she told the resident to get back in bed. LPN #3 stated that the resident rolled his legs up on the bed and got back in bed. LPN #3 stated that there was no RN in the building, so she assessed the resident. LPN #3 said there is an RN on call, but there have been occasions when the on-call RN does not answer. She said one of the on-call RNs cannot be reached on Sundays between 11:00 a.m. to 1:00 p.m. c. At 3:15 p.m., the Director of Nursing (DON) stated that when a resident falls, an RN should be called before removing the resident from the floor. 2. Resident #2 has [DIAGNOSES REDACTED]. Review of the Incident and Accident (I/A) Reports revealed the following: a. On 3/1/17, LPN #3 documented that the resident was found leaning against her bed sitting on the mat, and the RN was made aware of the incident. LPN #3 documented that the resident's Range of Motion was adequate. Review of the Integrated Progress Notes and I&A revealed no RN assessment. b. On 3/6/17, the resident was found on the floor with her call bell ringing and stated she rolled out of bed. The investigation form revealed that the resident's bed alarm was not plugged into the call system. When interviewed on 3/13/17 at 9:50 a.m., the Nurse Manager stated that when the resident was found on the floor on 3/1/17, the RN was made aware of the incident, but did not complete an assessment prior to moving the resident. She said on 3/6/17, there was no investigation to determine why the bed alarm was not plugged in. The facility policy and procedure, Accident and Incident Reporting Form Completion Procedure (Resident), revised 6/19/14, revealed that an accident shall be reported to the supervisor immediately when any staff member witnesses or becomes aware of such an occurrence. (10 NYCRR 415.11(c)(3)(i))

Plan of Correction: ApprovedApril 6, 2017

The preparation and execution of this plan of correction does not constitute admission or agreement with the facts alleged or conclusions set forth in this statement of deficiencies. This plan of correction is executed solely because it is required by Federal law.
1. Resident #1 on 2/26/17 and resident #2 on 3/2/17 and 3/6/17 have been assessed by an RN and no injury was noted on either resident. Further investigation regarding resident #2, the bed alarm was in working order on 3/6/17 and 2 weeks of auditing showed no issues with the bed alarm.
2. Incident and accident reports have been reviewed by the IDT team for the last 4 weeks. RN assessments have been completed on every resident with a fall beginning 3/21/17. Any falls resulting in injury were addressed immediately by a RN beginning 3/21/17.
3. The on-call RN schedule was reviewed by the DON on 2/27/17. When to notify the RN was reviewed and revised on 3/27/17. RN on-call guidelines reviewed by the DON on 4/5/17. RN assessment guidelines were revised by the DON 4/5/17. The Staff Development Coordinator educated all departments on the on-call RN schedule on 2/27/17. The Staff Development Coordinator or her designee will instruct Nursing Staff on when to notify the RN by 4/11/17. The Staff Development Coordinator or her designee will instruct Registered Nurses on the RN Assesment Guidelines by 4/11/17.
4. All residents who need RN assessment prior to moving the resident after a fall will be audited by the Nurse Managers or their designee weekly for four weeks then monthly and then intermittently as determined by the QA Committee to ensure that the RN assessment was completed. The results of these audits will be provided to the QA Committee for their review and action as necessary.
The Nurse Managers will be responsible for the correction of this deficiency.