Chemung County Health Center-Nursing Facility
January 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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 24, 2018
Corrected date: March 23, 2018

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 740) completed on 1/24/18, it was determined that for two of three residents reviewed for abuse, neglect, or mistreatment, the facility did not ensure the residents were free from mistreatment and abuse. The issues were incidents involving Residents #1 and #2. This is evidenced by the following: The facility policy, Resident Abuse and Elder Justice Act, reviewed (MONTH) (YEAR), included investigation guidelines for abuse, neglect and mistreatment. Mistreatment is defined as the inappropriate use of medication, isolation or use of physical/chemical restraints, and neglect included failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/17/17, included that the resident had severely impaired cognition and physical behavioral symptoms directed toward others. Resident #1's Comprehensive Care Plan (CCP), initiated 4/27/17, included a history of delusions and agitated behaviors. Interventions included gentle reorientation with casual conversation and validation when resident expresses delusional thoughts. The Bedside Kardex Report, effective (MONTH) (YEAR), directed to use a calm approach, validation approach, do not attempt to reorient the resident and leave and return if agitated. Resident #2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/15/17, included that the resident had severely impaired cognition and physical and verbal behavioral symptoms directed towards others. Resident #2's CCP, initiated 11/8/16, included angry outbursts and combative behaviors. The Bedside Kardex Report, effective (MONTH) (YEAR), directed to use a gentle approach, calm voice and stop if resident becomes aggressive. Gain resident cooperation before resuming care and report behaviors to a nurse. The Health Electronic Response Data System, dated 12/28/17, revealed that on 12/27/17, a report was received from the Nurse Manager that an allegation of abuse occurred on 12/26/17 at 5:30 p.m. The allegation was that Certified Nursing Assistant (CNA) #1 told Resident #1 that she was going to drown her stuffed cats (Resident #1 believes the stuffed cats are real). During the investigation process, another allegation regarding CNA #1 surfaced involving CNA #1 tapping Resident #2 on the head with a pillow and/or Bible. CNA #1 admitted she threatened to drown Resident #1's cats and stated that she teasingly tapped Resident #2 with no intent to harm. The facility summary, dated 12/27/17, revealed that after interviewing all staff members, it appeared that CNA #1 used inappropriate language towards Resident #1 when she became agitated with Resident #1's behavior. Two additional witnesses corroborated the allegations. When interviewed on 1/11/18 at 11:40 a.m., the Administrator stated that allegations of abuse/mistreatment involving Residents #1 and #2 were reported by the Licensed Practical Nurse (LPN) on 12/27/17 at 3:00 p.m. The Administrator stated that the incident involving Resident #1 occurred on 12/26/17, and the incident involving Resident #2 occurred previous to that and the exact date was unknown. The Administrator stated that he spoke with staff regarding timely reporting, and directed staff to report if not sure and administration would investigate. When interviewed on 1/11/18 at 12:15 p.m., CNA #2 stated that around 12/19/17 at 9:30 p.m. when completing Resident #2's care with CNA #1, the resident became very combative, and CNA #1 placed a pillow over the resident's face using two hands for about three seconds. CNA #2 stated that Resident #2 tried to remove the pillow lifting with her right hand, but CNA #2 removed the pillow. CNA #2 stated that after removing the pillow, the CNAs tried to remove Resident #2's shirt, and CNA #1 picked up a Bible and hit Resident #2 on the middle of her forehead because CNA #1 was annoyed. CNA #2 stated that Resident #2 tried to remove the Bible from CNA #1's hand and tried to hit and spit, and CNA #1 placed the Bible on the table, and told Resident #2 that was not acceptable, covering the resident's mouth with her hand. CNA #2 stated that on 12/26/17, she observed CNA #1 take Resident #1's stuffed cats. CNA #2 said the resident thinks the cats are real. CNA #1 told the resident that she was going to throw the cats in the river. CNA #2 stated that the nurse was at the nurses' station at that time and could see and hear the interaction. CNA #2 stated that she asked CNA #1 why she said that, and CNA #1 said she did not know, she was just mad. When interviewed on 1/11/18 at 1:00 p.m., CNA #3 stated that around 12/21/17, she was providing care to Resident #2 with CNA #1, and the resident was trying to hit and was calling the CNAs names. CNA #1 took Resident #2's Bible and tapped the resident on her head. CNA #3 stated that was inappropriate but CNA #1 was not trying to do harm, she was annoyed and agitated with Resident #2. When interviewed on 1/11/18 at 1:50 p.m., CNA #1stated that for the incident involving Resident #1, the resident was throwing her stuffed animals and hitting and spitting at staff. CNA #1 told the resident that she cannot do that, it was not nice, and if she did not stop, CNA #1 would throw the cats in the river. CNA #1 stated that she heard the same thing said to the resident before, so it just came out. CNA #1 stated that she did place a pillow on Resident #2's head, kind of joking, adding that she bopped the resident with the pillow. CNA #1 stated that the facility protocol for agitated residents included walking away from the resident. CNA #1 said that she does not feel she received proper training for residents with combative behaviors. When interviewed on 1/11/18 at 2:50 p.m., the LPN stated that on 12/26/17, she saw CNAs #1 and #2 with Resident #1. CNA #1 leaned forward and was close to the resident's face and said she was going to take her cats and drown them in the river. The LPN stated that she saw CNA #1 place her full hand over the resident's mouth for a few seconds because the resident was spitting. The LPN said she told the CNAs to walk away from the resident. (10 NYCRR 415.4(b)(1)(i))

Plan of Correction: ApprovedFebruary 12, 2018

Residents and Areas Affected by Deficiency:
On 12/27/17, both resident #1 and resident #2 were assessed for any physical and psychological harm. Both residents were unable to recall either associated incident, and there were no signs of any psychological or physical harm.
CNA #1 was suspended and removed from the unit immediately upon report of potential abuse to Administration. CNA #1 was terminated from employment effective 12/28/17 upon conclusion of facility investigation.
CNA #2, CNA #3, and LPN #1 individually met with Administrator and Director of Nursing to review definitions of Abuse, Neglect, Mistreatment, and Exploitation. All staff members acknowledged prior, clear understanding of guidelines during initial investigation as well as upon conclusion of DOH investigation. CNA #2, CNA #3, and LPN #1 received disciplinary action upon conclusion of the facility?s investigation.
Identifying Other Residents/Areas:
All residents could be at potential risk from a recurrence of this deficiency so the Measures and Systemic Changes stated below are intended to correct this deficiency for all current and future residents.
Measures and Systemic Changes:
1. An immediate facility-wide re-education on identification and reporting of Abuse, Neglect, Mistreatment and Exploitation was initiated on 12/27/17. The education included all employees. The education included guidelines for timely reporting, who to report to, and definitions of the different types of Abuse, Neglect, Mistreatment, and Exploitation, with emphasis placed on ?when in doubt, report immediately.?
2. A review of the Facility?s Policy and Procedure was conducted on 1/3/18 and it was determined that the policy and procedure met and reflected all regulatory requirements for Abuse Reporting.
3. An audit tool will be developed to gauge staff?s understanding of the definitions of Abuse, Neglect, Mistreatment, and Exploitation. Any identified knowledge deficits will immediately be addressed with a re-education. The Director of Nursing or designee will also conduct a follow-up with the identified individual within a reasonable timeframe.
Quality Assurance Program:
A monthly audit will be conducted by the Clinical Supervisor or designee. A report of the audit findings will be submitted to the Director of Nursing who will report quarterly to the QAPI committee. This audit will now be a permanent quarterly QAPI report.
Person Responsible for Completion:
Director of Nursing

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: January 24, 2018
Corrected date: March 23, 2018

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 740) completed on 1/24/18, it was determined that for two of three residents reviewed for abuse, neglect or mistreatment, suspicion of abuse, neglect and/or mistreatment was not reported by facility staff to administration in a timely manner. The issue involved delayed reporting of mistreatment/abuse/neglect incidents involving Residents #1 and #2. This is evidenced by the following: The facility policy, Resident Abuse and Elder Justice Act, reviewed (MONTH) (YEAR), included Investigation Guidelines for abuse, neglect and mistreatment. The policy included immediate investigation of all reports of suspected abuse or mistreatment by the on-site Administrative Authority and prompt contact of the Administrator and Director of Nursing (DON). Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/17/17, included that the resident had severely impaired cognition and physical behavioral symptoms directed toward others. Resident #2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/15/17, included that the resident had severely impaired cognition and physical and verbal behavioral symptoms directed towards others. The Health Electronic Response Data System, dated 12/28/17, revealed that on 12/27/17, a report was received from the Nurse Manager that an allegation of abuse occurred on 12/26/17 at 5:30 p.m. The allegation was that Certified Nursing Assistant (CNA) #1 told Resident #1 that she was going to drown her stuffed cats (Resident #1 believes the stuffed cats are real). During the investigation process, another allegation regarding CNA #1 surfaced involving CNA #1 tapping Resident #2 on the head with a pillow and/or Bible. CNA #1 admitted she threatened to drown Resident #1's cats and stated that she teasingly tapped Resident #2 with no intent to harm. When interviewed on 1/11/18 at 11:40 a.m., the Administrator stated that allegations of abuse/mistreatment involving Residents #1 and #2 were reported by the Licensed Practical Nurse (LPN) on 12/27/17 at 3:00 p.m. The Administrator stated that the incident involving Resident #1 occurred on 12/26/17, and the incident involving Resident #2 occurred previous to that and the exact date was unknown. The Administrator said that the staff are expected to report suspicion of abuse/neglect or mistreatment immediately. When interviewed on 1/11/18 at 11:55 p.m., the DON stated that CNA #2 reported the incidents involving Resident #2 during the investigation process involving Resident #1's incident that occurred on 12/26/17, stating that CNA #2 felt tormented by the events involving Resident #2 and was losing sleep. When interviewed on 1/11/18 at 12:15 p.m., CNA #2 stated that around 12/19/17 at 9:30 p.m., when completing Resident #2's care with CNA #1, she observed CNA #1 place a pillow over the resident's face using two hands for about three seconds and hit Resident #2 on the middle of her forehead with a Bible because CNA #1 was annoyed. CNA #2 stated that on 12/26/17, she observed CNA #1 take Resident #1's stuffed cats. CNA #2 said the resident thinks the cats are real. CNA #1 told the resident that she was going to throw the cats in the river, and the nurse was at the nurses' station at that time and could see and hear this interaction. CNA #2 stated she did not report the incidents because she was afraid she would get in trouble. CNA #2 said that the nurse did not report the incident until 22 hours later, because she had 24 hours to report. When interviewed on 1/11/18 at 1:00 p.m., CNA #3 stated that around 12/21/17, she was doing care on Resident #2 with CNA #1. She said CNA #1 took Resident #2's Bible and tapped the resident on her head. CNA #3 stated that she was shocked by the situation and did not know what to do and reported the incident after another incident occurred involving CNA #1 and Resident #1 on 12/26/17. CNA #3 said that CNA #1 was doing other things to other residents. CNA #3 stated that abuse was supposed to be reported immediately to the nurse, but she felt intimidated by CNA #1. When interviewed on 1/11/18 at 1:50 p.m., CNA #1 stated that for the incident involving Resident #1, the resident was throwing her stuffed animals and hitting and spitting at staff. CNA #1 told the resident that she cannot do that, it was not nice, and if she did not stop, CNA #1 would throw the cats in the river. CNA #1 stated that she heard the same thing said to the resident before, so it just came out. CNA #1 stated that she did place a pillow on Resident #2's head, kind of joking, adding that she bopped the resident with the pillow. CNA #1 stated that the facility protocol for agitated residents included walking away from the resident. CNA #1 said that she does not feel she received proper training for residents with combative behaviors. When interviewed on 1/11/18 at 2:50 p.m., the LPN stated that on 12/26/17, she saw CNAs #1 and #2 with Resident #1. She said CNA #1 leaned forward and was close to the resident's face and said she was going to take her cats and drown them in the river. The LPN stated that she saw CNA #1 place her full hand over the resident's mouth for a few seconds because the resident was spitting. The LPN said that she told the CNAs to walk away from the resident. The LPN stated that after discussing the incident with another LPN, she was advised that this was abuse, it needed to be reported, and reported the incident on 12/27/17 at 3:00 p.m., when she returned to work. The LPN stated that she got mixed up with state reporting and reporting to facility supervisors, and did not report the incidents until 12/27/17 at 3:00 p.m. when she returned to work. When interviewed by telephone on 1/25/18 at 11:20 a.m., Registered Nurse (RN) #1 stated that she worked as a supervisor on the evening shift during the month of (MONTH) (YEAR), and was not notified of any allegations of abuse or mistreatment. She said if either incident was reported to her, she would have removed the staff involved from the unit. RN #1 stated that she makes rounds two to three times during the shift and talks with staff during rounds. When interviewed by telephone on 1/25/18 at 11:30 a.m., RN #2 stated that she heard about the incidents involving Residents #1 and #2 after the fact, and no one reported either incident to her when she worked the evening shift as supervisor in (MONTH) (YEAR). RN #2 stated that Resident #1 thinks her stuffed cats are alive and would be extremely upset if someone threatened to drown them. (10 NYCRR 415.4(b)(2))

Plan of Correction: ApprovedFebruary 12, 2018

Residents and Areas Affected by Deficiency:
On 12/27/17, both resident #1 and resident #2 were assessed for any physical and psychological harm. Both residents were unable to recall either associated incident, and there were no signs of any psychological or physical harm.
CNA #1 was suspended and removed from the unit immediately upon report of potential abuse to Administration. CNA #1 was terminated from employment effective 12/28/17 upon conclusion of facility investigation.
CNA #2, CNA #3, and LPN #1 individually met with Administrator and Director of Nursing to review definitions of Abuse, Neglect, Mistreatment, and Exploitation. All staff members acknowledged prior, clear understanding of guidelines during initial investigation as well as upon conclusion of DOH investigation. CNA #2, CNA #3, and LPN #1 received disciplinary action upon conclusion of the facility?s investigation.
Identifying Other Residents/Areas:
All Residents could be at potential risk from a recurrence of this deficiency so the Measures and Systemic Changes stated below are intended to correct this deficiency for all current and future residents.
Measures and Systemic Changes:
1. An immediate facility-wide re-education on identification and timely reporting of Abuse, Neglect, Mistreatment, and Exploitation was initiated on 12/27/17. The education included all employees. The re-education included guidelines for timely reporting, facility reporting mechanisms (including who to report to), and definitions of the different types of Abuse, Neglect, Mistreatment, and Exploitation. All staff were re-educated to report any suspicion of Abuse, Neglect, Mistreatment, and Exploitation immediately.
2. A review of the Facility?s Policy and Procedure was conducted on 1/3/18 and it was determined that the policy and procedure met and reflected all regulatory requirements for timely Abuse Reporting.
3. New Abuse Reporting posters will be created and placed throughout the facility. The posters will highlight what to report, when to report, who to report (to), where to report, and why to report.
4. An audit tool will be developed to gauge staff?s understanding of timely reporting guidelines for Abuse, Neglect, Mistreatment, and Exploitation. Any identified knowledge deficits will be immediately addressed with a re-education. The Director of Nursing or designee will also conduct a follow-up with the identified individual within a reasonable timeframe.
Quality Assurance Program:
A monthly audit will be conducted by the Clinical Supervisor or designee A report of the audit findings will be submitted to the Director of Nursing who will report quarterly to the QAPI committee. This audit will now be a permanent quarterly QAPI report.

Person Responsible for Completion:
Director of Nursing