Terrace View Long Term Care Facility
July 16, 2018 Complaint Survey

Standard Health Citations

FF11 483.12(b)(1)-(3):DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95,

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 16, 2018
Corrected date: September 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Abbreviated survey (Complaint # NY 047) completed on 7/16/18, the facility did not implement written policies and procedures for training and screening employees, that would prohibit and prevent abuse, neglect for one (Resident #1) of four residents reviewed for abuse. Specifically, there was no evidence the Hospital Public Safety Assistants (PSA's) were provided with training on abuse, abuse prevention, understanding behavioral symptoms of residents, and nursing home resident care policies prior to being assigned duties in the nursing home. Additionally, the facility did not provide documentation that verified two Hospital Public Safety Assistants (PSA #1, PSA #2) of 30 employees that were subject to the New York State (NYS) Nurse Aide Registry checks prior to their assignment in the Skilled Nursing Facility. The findings are: Review of a facility policy and procedure entitled Abuse Prevention, Investigation and Reporting dated as revised 10/2012 revealed it is the policy of the facility to provide a safe, abuse free environment; educate all staff to recognize signs and symptoms of abuse, mistreatment or neglect. All employees will be screened for history of abuse, mistreatment or neglect of residents by checking with appropriate licensing boards and registries. Review of an Employee Job Description for a Hospital Public Safety Assistant dated 4/2018 revealed the work involves assisting in providing a safe environment for employees, visitors and individuals being treated and security for the facilities of the hospital or any of the offsite facilities or programs. In accordance with the New York State Office of Mental Health, the incumbent provides a safe environment for those patients diagnosed with [REDACTED]. The Essential Job Functions include assisting clinical staff in maintaining a therapeutic environment in patient care areas including physically intervening to prevent injury to patient, staff or visitor. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/21/18 revealed the resident had no cognitive impairment and was independent in decision making. Review of the care plan dated 8/13/17 revealed the resident had behavioral symptoms including a history of being verbal and physically aggressive, making inappropriate statements, being inappropriate to others, and hitting/banging on the wall and kicking items. The resident resided on an all-male locked behavioral unit. The care plan dated 3/26/18 used by the Certified Nursing Assistants (CNA) to provide care documented they were to refer to the Adaptive Care Plan in front of the resident's chart for floor/activity/out on pass privileges. May use CPI (Crisis Prevention Institute, international training organization that specializes in the safe management of disruptive and assaultive behavior) de-escalation techniques. Review of a Format for Offsite Investigation form dated 11/3/17 revealed the resident was off the unit at the facility cafeteria with a Hospital Public Safety Assistant (PSA #1) and CNA #1 when he allegedly made an inappropriate comment. PSA #1 attempted to remove the resident from the cafeteria and a scuffle ensued with the resident ending up on the floor. After review of the surveillance video, the facility determined PSA #1 mishandled the behavior and he was removed permanently from the unit. Review of a Format for Offsite Investigation form dated 6/9/18 revealed Resident #1 entered Resident #2's room at the permission of Resident #2. PSA #2 entered the Resident #2's room and asked Resident #1 to leave as Resident #1 was rummaging through Resident #2's drawers. CNA #2 entered the room and advised Resident #1 to leave the room. The resident became agitated telling the PSA and CNA that he could be in there. The resident slammed the door against the wall and raised his arm to strike the PSA. The PSA blocked the strike and the resident lost balance and fell . The resident sustained [REDACTED]. Conclusion after the investigation and interviews: Resident has a history of aggressive combative behaviors and compliance issues at times with reasonable requests. PSA removed himself from the unit. Determination with the help of HR (Human Resources) and PSA manager that too much or appropriate response used. PSA may need re- training on de-escalation techniques. Final action taken: PSA removed from unit during investigation. No inappropriate physical contact determined. No intent to injury resident. Request for PSA to have further education re: appropriate interventions as assessed by his manager. Review of a Witness Statement dated 6/9/18 at 8:00 PM and signed by CNA #2 revealed, PSA #2 asked Resident #1 to leave Resident #2's room and to stop going through the possessions of another resident. Resident #1 was non- compliant and ignored the PSA's request. I asked Resident #1 to please stop and leave the room. Resident #1 violently slammed the door into the wall, turned around and attempted to punch PSA #2. PSA #2 blocked and pushed Resident #1 into the hallway. Resident #1 lost total balance, hit his head on the wall in the hallway during the fall. The PSA and the resident apologized to each other, situation/altercation de-escalated. Review of the medical record revealed a note by the Registered Nurse (RN #2) Supervisor dated 6/9/18 at 9:34 PM documenting the PSA and CNA went to tell Resident #1 to leave the Resident #2's room. The writer saw this resident flying across the hallway floor and bump his head on the wall on the opposite side of the hall. Review of an untitled and undated document provided by the facility and signed by RN #3 Unit Manager, documented the resident was interviewed on 6/10/18 regarding the event that occurred on 6/9/18 during the 3:00 PM to 11:00 PM shift. Resident #1 stated he was in another resident's room getting pennies out of the drawer. The PSA saw him and told him to leave the room. They argued and the resident stated, he 'flexed on the PSA meaning he raised his fist as to threaten the PSA, but he did not intend to hit him. He also said he did strike the wall in anger. He then said the PSA pushed him out of the room.' Review of a Witness Statement dated 6/12/18 at 2:45 PM and signed by PSA #2 revealed, myself and CNA #2 entered room and I began to ask (Resident #1) why he was going through Resident #2's belongings. Resident #1 ignored me and my questions. CNA #2 asked him to leave, Resident #1 went towards door slamming it against the wall, turned around and swung on me. At this time, I blocked it and pushed Resident #1 to create distance. Resident #1 tripped and fell back out of the room. During an interview on 6/27/18 at 3:30 PM, the Administrator stated the PSA staff are assigned only to the male behavioral unit and not used on any other unit of the nursing home. The PSA's are hospital employees and not employees of the nursing home. They are assigned to spend their shift on the unit to de-escalate residents' behavior if needed. Since they are not nursing home employees, they do not receive the same education for resident behavior as the nursing home staff. During an interview on 6/28/18 at 9:45 AM, the Director of Police and Security stated the PSA's are hired primarily for the behavioral units of the hospital, and are also assigned to the male behavioral unit of the nursing home. During an interview on 6/28/18 at approximately 3:10 PM, PSA #2 stated, Resident #1 became angry and slammed the door against the wall, and tried to punch the PSA, when he was asked to leave Resident #2's room by himself and CNA #2. PSA #2 put one hand up to deflect the resident's swing and pushed the resident to make space between himself and the resident. He stated that he did not mean to push the resident that hard. PSA #2 stated he received the NYS training through the hospital in Preventing and Managing Crisis Situations. During an interview on 6/28/18 at approximately 3:30 PM RN #2 Supervisor stated she was at the desk when she saw the resident fly out of the room across the hallway floor and hit his head on the opposite wall. During an interview on 6/29/18 at 2:30 PM, the Director of Nursing (DON) stated she did watch the surveillance video of the incident, and she did not think there was anything wrong with the way the PSA handled the incident. The resident had such a history of violent behavior and the PSA had to defend himself from being punched. Although the video does not show what happened in the room, the CNA verified the PSA account of the incident. There was another resident in the room as well, who needed to be kept safe. The DON agreed with the overall handling of the case. During an interview on 6/28/18 at 3:00 PM, the Assistant Director of Nursing (ADON) stated she does the training for the nursing home staff. The PSA's are hospital staff and not included in the training specific to the de-escalation techniques presented to nursing home staff. 2. Review of facility and agency staff employee files on 6/27/18, for compliance with the NYS Nurse Aide Registry regulations, revealed the following: PSA #1 started working at the facility as a PSA on 10/5/15. There was no Nurse Aide Registry Verification Report completed. PSA #2 started working at the facility as a PSA on 2/13/18. There was no Nurse Aide Registry Verification Report completed During an interview on 6/27/18 at 3:30 PM, the Nursing Home Administrator stated the PSA staff are hospital employees and are not providing hands on care. The PSA was there due to the violent history of Resident #1. He reported the PSA had to be a licensed security guard and therefore not requiring criminal history record checks. He did not think they would require a NYS Nurse Aide Registry Verification because they are hospital employees. During an interview on 6/28/18 at 9:45 AM, the Director of Police and Security stated the PSA must be a licensed security guard and does not require criminal history record checks. He was unaware that once they crossed the threshold to the nursing home that a NYS Nurse Aide Registry Verification check was required. 415.4(b)

Plan of Correction: ApprovedAugust 10, 2018

F607 ?Çô Corrective Action ?Çô To assure that the facility follows policies and procedures that prohibit abuse, neglect, exploitation of residents and misappropriation of resident property; the following plan will be implemented. 1) On 7/16/18 the Nurse Aide Registry checks were ran for all 34 Hospital Public Safety Assistants (PSAs) with no findings. In addition, as of 7/23/18 the PSAs have been officially removed from Terrace View and will not be used in the future. 2) All current employee?ÇÖs will be reviewed for verification that the Nurse Aid Registry has been checked, and that training on abuse, neglect, exploitation of residents, misappropriation of resident property, and understanding behavioral symptoms of residents has occurred. 3) The policy and procedure for preforming Nurse Aid Registry checks will be reviewed and revised (if necessary). The Administrator will in-service the Human Resource Business Partner and appropriate HR staff on the importance of checking the Nurse Aid Registry before hire and the revised policy/ procedure (if necessary). All staff receive training on abuse, neglect, exploitation of residents, misappropriation of resident property, and understanding behavioral symptoms of residents upon hire and annually. 4) To ensure prevention of future deficient practice, The Human Resource Business partner/ Designee/and Inservice staff /Designee will perform monthly audits of all newly hired employees for the next 3 months and then as needed based on the audit findings. Audits will verify that the Nurse Aid Registry report is being run prior to hire and that all training on abuse, neglect, exploitation, misappropriation of residents property, and understanding residents behavioral symptoms has occurred prior to stat of job duties. The Administrator will monitor this process and will review the results monthly at the Quality Assurance Performance Improvement meetings. The Administrator will assume overall responsibility for the correction of F607.

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: July 16, 2018
Corrected date: September 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during an Abbreviated survey (Complaint #NY 047) completed on 7/16/18, the facility did not ensure that alleged violations involving abuse are reported immediately, but not later than two 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 officials in accordance with State Law as required for one (Residents #1) of four residents. Specifically, the facility did not report within two hours that a Hospital Public Safety Officer (PSA) allegedly pushed Resident #1 resulting in a minor injury. The finding is: Review of a facility policy and procedure entitled Abuse Prevention, Investigation and Reporting dated as revised 10/2012 revealed it is the policy of the facility to provide a safe, abuse free environment; educate all staff to recognize signs and symptoms of abuse; investigate all alleged abuse, mistreatment or neglect and to protect residents from further abuse while conducting the investigation and to report any occurrence of abuse, mistreatment or neglect to the appropriate authorities and the New York State Department Of Health (NYS DOH). 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/21/18 revealed the resident had no cognitive impairment and was independent in decision making. Review of a Format for Offsite Investigation form dated 6/9/18 revealed Resident #1 entered Resident #2's room at the permission of Resident #2. PSA #2 entered the Resident #2's room and asked Resident #1 to leave as Resident #1 was rummaging through Resident #2's drawers. CNA #2 entered the room and advised Resident #1 to leave the room. The resident became agitated telling the PSA and CNA that he could be in there. The resident slammed the door against the wall and raised his arm to strike the PSA. The PSA blocked the strike and the resident lost balance and fell . The resident sustained [REDACTED]. Conclusion after the investigation and interviews: Resident has a history of aggressive combative behaviors and compliance issues at times with reasonable requests. PSA removed himself from the unit. Determination with the help of HR (Human Resources) and PSA manager that too much or appropriate response used. PSA may need re- training on de-escalation techniques. Final action take: PSA removed from unit during investigation. No inappropriate physical contact determined. No intent to injury resident. Request for PSA to have further education re: appropriate interventions as assessed by his manager. Review of a Witness Statement dated 6/9/18 at 8:00 PM and signed by CNA #2 revealed, PSA #2 asked Resident #1 to leave Resident #2's room and to stop going through the possessions of another resident. Resident #1 was non- compliant and ignored the PSA's request. I asked Resident #1 to please stop and leave the room. Resident #1 violently slammed the door into the wall, turned around and attempted to punch PSA #2. PSA #2 blocked and pushed Resident #1 into the hallway. Resident #1 lost total balance, hit his head on the wall in the hallway during the fall. The PSA and the resident apologized to each other, situation/altercation de-escalated. Review of the medical record revealed a note by the Registered Nurse (RN #2) Supervisor dated 6/9/18 at 9:34 PM documenting the PSA and CNA went to tell Resident #1 to leave the other residents room. The writer saw this resident flying across the hallway floor and bump his head on the wall on the opposite side of the hall. Review of a untitled undated document provided by the facility and signed by RN #3 Unit Manager, documented the resident was interviewed on 6/10/18 regarding the event that occurred on 6/9/18 during the 3:00 PM to 11:00 PM shift. Resident #1 stated he was in another resident's room getting pennies out of the drawer. The PSA saw him and told him to leave the room. They argued and the resident stated, he 'flexed on the PSA meaning he raised his fist as to threaten the PSA, but he did not intend to hit him. He also said he did strike the wall in anger. He then said the PSA pushed him out of the room.' Review of a Witness Statement dated 6/12/18 at 2:45 PM and signed by PSA #2 revealed, myself and CNA #2 entered room and I began to ask (Resident #1) why he was going through Resident #2's belongings. Resident #1 ignored me and my questions. CNA #2 asked him to leave, Resident #1 went towards door slamming it against the wall, turned around and swung on me. At this time I blocked it and pushed Resident #1 to create distance. Resident #1 tripped and fell back out of the room. During an interview on 6/27/18 at 3:30 PM, the Administrator stated he had discussed this incident with his team including the Director of Police and Security and the hospital in-service staff and referred to the NYS Reporting Manual for guidance. Since there was no violation of the care plan and all agreed the incident was handled according to training he did not believe the incident required reporting to the NYS Department of Health. During an interview on 6/28/18 at 9:45 AM, the Director of Police and Security stated the PSA's job was to protect the staff, other residents and himself. Using force depends on the situation and in this case, according to PSA #2 and CNA #2, Resident #1 was going to punch the PSA. The PSA held up his arms and pushed Resident #1 away to create space. This was justified in that the PSA needed to defend himself and get distance from the resident. He reported the PSA's are hired primarily for the behavioral units of the hospital but are also assigned only to the male behavioral unit of the nursing home. During an interview on 6/29/18 at 2:40 PM, the Medical Director stated he had read and signed the incident report per the facility protocol but had not viewed the surveillance video of the incident. He did not believe the staff acted inappropriately given the situation and the history of the resident's behavior. During an interview on 6/29/18 at 2:30 PM, the Director of Nursing (DON) stated she had reviewed the surveillance video of the incident and did not think there was anything wrong with the way the PSA handled the incident. The resident had such a history of violent behavior and the PSA had to defend himself from being punched. The video does not show what happened in the room, the CNA verified the PSA account of the incident. There was another resident in the room as well, who needed to be kept safe. The DON agreed with the overall handling of the case. After discussion with Administration, she agreed this incident did not rise to the level of reporting to the NYS Department of Health. 415.4(b)(4)

Plan of Correction: ApprovedAugust 10, 2018

F609 ?Çô Corrective Action ?Çô To assure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State Law though established procedure (including to the State survey and certification agency ?Çô New York State Department of Health (NYSDOH), the following plan will be implemented. 1) As noted in the finding, the NYSDOH became aware of the incident during an investigation of complaint # NY 047 completed on 7/16/18. The incident was reviewed with all responsible staff on 7/18/18 2) All residents with alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source and misappropriation of resident property have the potential to be affected by this deficient practice. A retrospective review of all residents who have such incidents in the past 30 days will be created and reviewed to assure that proper notification took place (if necessary). 3) All Administrative/Nursing Administrative staff will in-serviced on the NYSDOH reporting guidelines, and incident reporting manual. The facility abuse policy will also be reviewed and revised (if necessary) to assure compliance with 483.12 4) To ensure prevention of future deficient practice, The Director of Nursing/Assistant Director of Nursing for QA/Designee will perform 10 random audits of all resident accident and incident investigations for the next 3 months and then as needed based on the audit findings. Audits will verify that the facility is appropriately reporting all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State Law though established procedure (including to the State survey and certification agency according to the guidelines set forth in the NYSDOH incident reporting manual. The Administrator will monitor this process and will review the results monthly at the Quality Assurance & Performance Review meetings as needed. The Administrator will assume overall responsibility for the correction of F609.