Brooklyn Gardens Nursing & Rehabilitation Center
June 12, 2017 Complaint Survey

Standard Health Citations

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities 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. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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: June 12, 2017
Corrected date: July 14, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey, it was determined that the facility did not ensure that an allegation of missing property was investigated. This was evident for 1 of 3 residents sampled for Misappropriation of Property (Resident #1). Specifically, Resident #1's daughter reported to the Social Worker (SW) and the Director of Nursing (DNS) that Resident #1's clothes were missing. The facility did not initiate an investigation regarding the missing clothes and the items were not replaced. Complaint # NY 498 The findings include: Resident #1 was an [AGE] year old female initially admitted to facility 12/9/2016 with [DIAGNOSES REDACTED]. The Minimum Data Set 12/16/2016 identified the resident Cognitive Patterns with a score of 12 points. The Admission or Incoming Personal Property List for Resident #1, revealed nine items on the list which included two pairs of shoes and five pieces of clothing and one cap or hat. This form did not have a date and was not signed by the accepting inventory staff, Resident #1 or the family member as required on the form. On 03/01/2017 at 3:09PM, the complainant was interviewed. She stated that she spoke with the SW about the missing items (does not remember the date) and the SW instructed her to bring in proof of purchase. She stated that on 01/17/2017 she provided the DNS with the receipt for the missing items. She further stated that she had not heard anything back from the facility and that she was not reimbursed for Resident #1's missing clothes. On 02/28/2017 at 12:29AM, the DNS was interviewed. She stated that Resident #1's daughter (complainant) came to the facility on [DATE] with a store receipt listing pieces of clothing items. The complainant also informed her that she was instructed to bring in the receipt. She also stated the complainant informed her that Resident #1's clothes were missing. She affirmed that she gave the receipt to the Director of Housekeeping to search for the missing clothes. Upon inquiry, the DNS stated that the SW did not initiate an investigation of the missing items and the DNS was unable to find the receipt. On 03/01/2017 at 2:48PM, the Director of Housekeeping (no longer works for the facility) was interviewed. He stated that he does not recall the DNS giving him any receipt or asking him to investigate or search for Resident #1's missing items. On 02/28/2017 at 11:31AM, the SW was interviewed. She stated that she spoke with Resident #1's daughter who reported to her that Resident #1's clothes were missing. Upon inquiry, the SW stated that she does not remember the date and that she did not document the conversation. She further stated that she instructed the complainant to come to the facility so they can discuss the items and that she should bring proof of purchase. The SW affirmed that she did not get to meet with the complainant and that she did not initiated an investigation. The Facility Policy & Procedures: Abuse Prohibition included Misappropriation of Resident Property, states that the facility will investigate all incidents in conjunction with the risk management program. The findings of investigation will be done in writing and kept with the risk management reports. Investigative report will summarize the findings and outcome as well as note any corrective action or follow up. The facility did not conduct an investigation of Resident #1's missing property and the missing items were not replaced. 415.4(B)(1)(ii)

Plan of Correction: ApprovedJune 16, 2017

1. Immediate Action:
Resident #1 was reimbursed for lost items.
Educational counseling was provided to the Social workers regarding timely initiation of the investigative process related to misappropriation of resident property and the grievance process.

2. How we will identify other residents with potential for the same practice:
All residents have the potential for the same practice.
All (YEAR) grievances will be also reviewed by the Interdisciplinary team to ensure all grievances were thoroughly investigated with documented resolutions. Any identified issues will be addressed.

3. Measures/systemic changes that were put in place:
Policies and Procedures were reviewed by the Administrator, Director of Nursing, Director of Social Services and the Director of facilities management. No changes were required.
All department heads will be re-educated on the policy and procedure of misappropriation of resident property with emphasis on immediate initiation of investigation of a resident grievance and timely follow-up to resident and/or representative.
All staff will be re-educated regarding the policy of misappropriation of residents property.
Attendance record and lesson plan will be filed for validation.

4. How the corrective action will be monitored:
The Social service staff will:
a) Number and log all grievances
b) Indicate whether each grievance was resolved and
c) Indicate the date of follow-up with resident and/or representative.
The log will be audited weekly x4 weeks then monthly x 6 months.
Findings will be addressed immediately and all findings will be reported to the Quality Assurance / Performance Improvement committee (QAPI) on a monthly basis.

5. Responsible person for correction:
Director of Social Services / Designee