Buffalo Center for Rehabilitation and Nursing
May 3, 2021 Complaint Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2021
Corrected date: June 7, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint # NY 451) completed on 5/3/21, the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #3) of three residents reviewed. Specifically, the facility did not provide adequate supervision to prevent the resident from eloping from the facility without staff's knowledge. The resident eloped from the facility on 5/1/21 and was found by staff walking alone in the parking lot. Additionally, there were no care plan interventions implemented when the resident exhibited exit seeking behaviors. Refer to: F725 s/s = L, Sufficient Nursing Staff The facility policy and procedure (P&P) Care Plans - Comprehensive, revision dated 10/2019, documented the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility P&P Wandering Residents, revision dated 8/2019, documented the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate if the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. The finding is: 1. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 4/15/21 documented the resident was sometimes understood, sometimes understands, and was cognitively intact. The MDS documented the resident required supervision for walking in the corridor. The Admission/Readmission Evaluation, dated 4/8/21, documented the resident was at low risk for elopement. Resident #3's Visual/Bedside Kardex Report (guide used by certified nurse aide (CNA) to provide care) dated 5/2/21 documented the resident was to be supervised when ambulating in the corridor. There was no documentation related to wandering or elopement risk on the report. The comprehensive care plan dated 4/29/21 documented Resident #3 exhibited wandering behaviors and was an elopement risk with a goal that the resident would not leave the facility unattended. There were no interventions on the comprehensive care plan for wandering or elopement. The Facility 24 Hour Report documented Resident #3 had exit seeking behaviors on 4/14/21, 4/15/21, 4/18/21, 4/20/21, 4/23/21, and 5/1/21. The electronic medical record (EMR) Progress Notes for Resident #3 documented the following: - 4/8/21 10:43 PM - Wandering on unit, exit seeking, attempting exit doors. - 4/9/21 10:10 PM - Resident continues to display behaviors, getting upset when they can't leave the unit, banging on the doors and shaking handles. - 4/10/21 1:12 PM - Resident was very aggressive, banging on the door to get off the unit. - 4/12/21 8:35 PM - Exit seeking, stating they needed to go home. - 4/15/21 7:25 PM - Resident attempted elopement during shift, set off door alarms. The RN Assessment dated 5/1/21 documented at 9:15 AM Resident #3 was observed wandering the hallways on the 4th floor, pushing at the fire exit doors, checking doorknobs, and attempted to pull the fire alarm multiple times. At 9:30 AM the fire alarm triggered. During observations on 5/2/21 between 6:10 AM and 10:20 AM Resident #3 was ambulating unsupervised in the 4th floor corridor. At 10:20 AM the resident triggered the delayed egress door on the C-Hall. During an interview on 5/2/21 at 9:58 AM, maintenance worker #1 stated the fourth floor C-Hall fire alarm pull station triggered on 5/1/21 at 9:20 AM and Resident #3 went down the stairwell. During an interview on 5/2/21 at 10:34 AM, the Food Service Director (FSD) stated the fire alarm sounded on 5/1/21 at approximately 9:30 AM and a staff member (Housekeeper #1) alerted her that a resident was alone, ambulating in the parking lot. The FSD immediately went outside and brought Resident #3 back into the building. During an interview on 5/2/21 at 11:04 AM, the Director of Nursing (DON) stated they were unaware Resident #3 had eloped from the building on 5/1/21. During an interview on 5/3/21 at 12:43 PM, the DON stated they reviewed the EMR 24-hour report and the handwritten 24-hour report daily but they were unaware of Resident #3's exit seeking behaviors. The DON stated the facility should have done another elopement risk assessment when the resident began to exhibit exit seeking behaviors, and that interventions to prevent elopement should have been care planned and implemented. 415.12(h)(2)

Plan of Correction: ApprovedMay 28, 2021

F-689 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices ?§483.25(d) Accidents. The facility must ensure that - ?§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and ?§483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 1. What Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #3 had another elopement assessment, and was issued a wanderguard on 5/1/21. 2.How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. We will audit the residents on the 4th floor reviewing their elopement scores etc., to ensure there is no one else needing a Wanderguard or care plan change. 3.What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur. If a resident develops exit seeking behavior, they will immediately have their wandering assessment recalculated, care plan updated, and a psych consult ordered. The Administrator instructed the Director of Maintenance/Designee to conduct wanderguard drills monthly. The RN Educator will reeducate all staff regarding Wandering, wanderguard?ÇÖs and Fire Drill Procedures. 4.How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice. The DON/ ADON will audit all wanderguard documentation weekly x4 weeks, then monthly x2 weeks and report all findings to the QAPI committee on a monthly basis. The Administrator will review the audits to ensure all discrepancies have been identified and the corrective action is implemented. The results of the Audits will be reviewed at the monthly QAPI meeting by the Administrator to ensure that regulatory The DON is responsible for this correction.

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2021
Corrected date: June 7, 2021

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 451) completed on 5/3/21, the facility did not have evidence that all alleged violations were thoroughly investigated for three (Residents #3, 4, and 5) of three residents reviewed for abuse and neglect. Specifically, there was a lack of investigation of resident to resident physical abuse (Residents #3, 4, and 5) and there was a delay in the investigation of an actual elopement (Resident #3). The findings are: Review of the facility policy and procedure (P&P) entitled Accident - Incidents, revised 7/2020 documented the following: An incident is any occurrence not consistent with the routine operation of the center, normal care of the resident, or observation of a condition which might be a safety hazard. The occurrence may involve abuse, neglect, and mistreatment or an injury of unknown origin. Regardless of how minor an accident/incident may be, it must be reported to the Nurse Manager or Nursing Supervisor. Review of the facility P&P entitled Abuse, revised 2/2019 documented the following: - Abuse - the willful infliction of injury. - Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. - Physical Abuse - includes hitting, slapping, pinching, scratching, spitting, holding roughly, kicking etc. - Allegations/reports of suspected abuse shall be promptly and thoroughly investigated by the facility. - The Administrator and Director of Nursing are responsible for investigating and reporting. 1a. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 4/15/21 documented the resident was sometimes understood, sometimes understands, and was cognitively intact. The MDS documented the resident had verbal behaviors directed towards others. Resident #4 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had moderate cognitive impairment, usually understands, and was usually understood. The MDS did not document any behaviors. Resident #5 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severe cognitive impairment, was usually understood, and sometimes understands. The MDS did not document any behaviors. Review of the General Progress Note dated 4/24/21 at 9:32 PM, written by Licensed Practical Nurse (LPN) #5, documented Resident #3 spit on Resident #4. The options Show on Shift Report and Show on 24 Hour Report were highlighted, which automatically adds the note on the electronic medical record 24-hour report. Review of Resident #4's electronic medical record revealed no documentation of the 4/24/21 incident with Resident #3. Review of the General Progress Note dated 4/24/21 at 9:45 PM, written by LPN #5, documented Resident #3 pulled Resident #5's hair and staff had to intervene. Resident #3 started yelling at staff, Resident #5, and the resident were separated from each other. This was reported to the Nursing Supervisor. The options Show on Shift Report and Show on 24 Hour Report were highlighted. Review of Resident #5's electronic medical record revealed no documentation of the 4/24/21 incident with Resident #3. Review of the handwritten Facility 24 Hour Report dated 4/24/21, evening shift, documented (Resident #3 had) behaviors throughout shift, spitting on a resident and the floor. During an interview on 5/3/21 at 12:25 PM, LPN #5 stated they had reported the incident to the Nursing Supervisor but could not recall which supervisor was on duty that evening. The facility was unable to provide to the surveyor investigations for the 4/24/21 resident to resident altercation between Residents #3 and 4. Nor was the facility able to provide an investigation for the 4/24/21 resident to resident altercation between Residents #3 and 5. During an interview on 5/3/21 at 12:43 PM, the Director of Nursing (DON) stated they reviewed the electronic medical record 24-hour report and the handwritten 24-hour report daily. The DON stated any resident to resident altercations, including spitting and hair pulling, would be considered abuse. The DON stated an accident/incident report (A/I) should be started immediately for each resident involved in resident to resident abuse. Additionally, the DON stated the facility did not complete investigations for the 4/24/21 resident to resident altercation between Residents #3 and 4, nor the 4/24/21 resident to resident altercation between Residents #3 and 5. During an interview on 5/3/21 at 1:28 PM, the Administrator stated all resident to resident altercations, including spitting and hair pulling, should have an A/I started immediately for each resident involved. The Administrator stated any LPN or Registered Nurse (RN) can initiate an A/I. b. Review of the RN Assessment dated 5/1/21 at 10:00 AM, written by Registered Nurse (RN) #1 documented at 9:15 AM Resident #3 was observed wandering the hallways on the 4th floor, pushing at the fire exit doors, checking doorknobs, and attempted to pull the fire alarm multiple times. At 9:30 AM the fire alarm triggered. During an interview on 5/2/21 at 10:09AM, the DON stated the facility did not initiate an A/I immediately for the elopement of Resident #3 on 5/1/21 because Resident #3 did not elope from the building. During an interview on 5/2/21 at 10:34 AM, the Food Service Director (FSD) stated the fire alarm sounded on 5/1/21 at approximately 9:30 AM and a staff member (Housekeeper #1) alerted them that a resident was alone, ambulating in the parking lot. The FSD immediately went outside and brought Resident #3 back into the building. Review of an untitled report identified as an incident/accident report by the facility, completed and dated 5/2/21 by RN #1, documented Resident #3 had an incident of elopement on 5/1/21 at 9:30 AM. During an interview on 5/3/21 at 1:28 PM, the facility Administrator stated an A/I was not immediately started for the elopement of Resident #3 because they weren't sure if Resident #3 had eloped from the building. 415.4(b)(3)

Plan of Correction: ApprovedMay 28, 2021

F-610 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation ?§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: ?§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. ?§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. ?§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. Residents #3 was sent to ECMC CPEP by the physician on 5/2/21 regarding continued exit seeking behavior. Resident now resides at Terrace View in stable condition. Resident #4 left AMA on 5/7/21 with her husband. Resident #5 remains in the facility in stable condition. Investigations for incidents involving residents #3, #3 and #4, and #3 and #5 were completed as per facility policy. The Nursing supervisors and LPN#5 will be counseled by the DON regarding the need for RN assessment and the importance of a thorough investigation, including obtaining of witness statements, of all resident incidents/ injury. The need to complete accident/ incident reports for all unusual occurrences will be stressed. All residents have the potential to be affected. The DON/ designee will review the last 60 days of incident reports/ 24-hour report sheets to ensure that all incidents/resident occurrences are appropriately investigated and assessed. Any issues noted will be immediately addressed. The RN Educator will educate licensed nursing staff on Investigative protocols and the facility Accident/Incident policy. The DON reviewed the facility ?Ç£Accident/Incident?Ç¥ and ?Ç£Investigation Protocols?Ç¥ with no revisions required. The DON will conduct 4 weekly Incident/ Investigation audits for a period of 12 weeks. Audits will ensure that all resident incidents/injuries/ unusual occurrences have thorough and complete investigation and subsequent RN assessment. The audit will include reviewing the 24hr report, to make sure no incidents are missed. Any issues noted will be immediately addressed. The results of the audits will be forwarded to the QAPI Committee for review and input. Responsibility: DON

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2021
Corrected date: June 7, 2021

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 451) completed on 5/3/21, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown origin, were reported immediately but no later than two hours after the allegation is made, if the events that caused the allegation involved abuse or resulted 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 Agency) for three (Residents #3,4,5) of three reviewed for abuse. Specifically, the facility did not report resident to resident abuse (Residents #3,4,5) within the two-hour timeframe, and the facility did not report an actual elopement (Resident #3) within the 24 hour timeframe to the New York State Department of Health (NYSDOH). The findings are: Refer to: F689 s/s = D, Accidents F725 s/s = L, Sufficient Nursing Staff The facility policy and procedure (P&P) Accident - Incidents, revised 7/2020, documented the following: An incident is any occurrence not consistent with the routine operation of the center, normal care of the resident, or observation of a condition which might be a safety hazard. The occurrence may involve abuse, neglect, and mistreatment or an injury of unknown origin. Regardless of how minor an accident/incident may be, it must be reported to the Nurse Manager or Nursing Supervisor. The facility P&P Abuse, revised 2/2019 documented the following: - Abuse - the willful infliction of injury. - Physical Abuse - includes hitting, slapping, pinching, scratching, spitting, holding roughly, kicking etc. - Allegations/reports of suspected abuse shall be promptly and thoroughly investigated by the Facility. - The Administrator and Director of Nursing are responsible for investigating and reporting. - Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident. 1a. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 4/15/21 documented the resident was sometimes understood, sometimes understands, and was cognitively intact. The MDS documented the resident had verbal behaviors directed towards others. Resident #4 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #4 had moderate cognitive impairment, usually understands, and was usually understood. The MDS did not document any behaviors. Resident #5 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #5 had severe cognitive impairment, was usually understood, and sometimes understands. The General Progress Note dated 4/24/21 at 9:32 PM, written by Licensed Practical Nurse (LPN) #5, documented Resident #3 spit on Resident #4. The options to Show on Shift Report and Show on 24 Hour Report were highlighted meaning the note was automatically added to the electronic medical record (EMR) 24-hour report. The General Progress Note dated 4/24/21 at 9:45 PM, written by LPN #5, documented Resident #3 pulled Resident #5's hair and staff had to intervene. Resident #3 started yelling at staff and Resident #5, and the residents were separated from each other. This was reported to the Nursing Supervisor. The options to Show on Shift Report and Show on 24 Hour Report were highlighted. Review of the handwritten Facility 24 Hour Report dated 4/24/21, evening shift, documented Resident #3 had behaviors throughout the shift, spitting on a resident and the floor. Review of the Aspen Complaint/ Incident Tracking System (ACTS) Report (software that logs and tracks nursing home complaints) from 4/24/21 to 5/3/21 revealed the incidents involving Resident #3, 4 and 5 were not reported to the NYSDOH. During an interview on 5/3/21 at 12:25 PM, LPN #5 stated they had reported the incident to the Nursing Supervisor but could not recall which supervisor was on duty that evening. During an interview on 5/3/21 at 12:43 PM, the Director of Nursing (DON) stated they reviewed the EMR 24-hour report and the handwritten 24-hour report daily. The DON stated any resident to resident altercations, including spitting and hair pulling would be considered abuse and be reportable to the NYSDOH. The DON stated they were unaware of the incidents between Resident #3, 4, and 5 on 4/24/21, therefore the resident to resident altercations were not reported to the NYSDOH. During an interview on 5/3/21 at 1:28 PM, the facility Administrator stated the incidents between Resident #3, 4, and 5 should have been reported to the NYSDOH within 2 hours of the incidents. The Administrator stated that they and the DON were responsible for reporting incidents. b. The RN Assessment dated 5/1/21 at 10:00 AM documented at 9:15 AM Resident #3 was observed wandering the hallways on the 4th floor, pushing at the fire exit doors, checking doorknobs, and attempted to pull the fire alarm multiple times. At 9:30 AM the fire alarm triggered. During an interview on 5/2/21 at 10:34 AM, the Food Service Director (FSD) stated the fire alarm sounded on 5/1/21 at approximately 9:30 AM and a staff member (Housekeeper #1) alerted her that a resident was alone, ambulating in the parking lot. The FSD immediately went outside and brought Resident #3 back into the building. Review of the facility's QA Report, identified as an incident/accident report by the DON, documented Resident #3 had an incident of elopement on 5/1/21 at 9:30 AM. Review of the Aspen Complaint/ Incident Tracking System (ACTS) Report (software that logs and tracks nursing home complaints) revealed the Resident #3's elopement incident was reported to the NYSDOH on 5/2/21 at 12:25 PM. During an interview on 5/3/21 at 12:43 PM, the DON stated there was a three-hour delay in the reporting of Resident #3's elopement. During an interview on 5/3/21 at 1:28 PM, the facility Administrator stated the elopement of Resident #3 on 5/1/21 should have been reported to NYSDOH within 24 hours of the incident. 415.4(b)(1)(i)

Plan of Correction: ApprovedMay 28, 2021

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-609 483.12(c)(1)(4) Reporting of Alleged Violations ?§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. Resident # 3 was discharged to the hospital on [DATE] and did not return to the facility. Resident # 4 left the facility AMA on 5/7/2021. Resident # 5 remains in the facility in stable condition. No adverse outcome was noted to above residents as a result of the delayed reporting. The care plans for above residents were reviewed and revised by the DON. The Regional RN also reviewed the indicated records and care plans with no issues identified. The last 60 days of accidents/incidents and allegations of abuse were reviewed by the DON to ensure that all were reported to the NYS DOH in a timely manner if indicated. No issues were identified. The DON, ADON and Unit Manager were educated by the Regional RN on 5/4/2021 regarding investigation protocols and reporting guidelines as per the facility Abuse policy and the NY State DOH Incident Reporting Manual. This education was subsequent to the three incidents cited in the SOD. The Administrator, Director of Nursing and the Nurse Management team will be re-educated on the Center?ÇÖs Abuse Policy and NYS DOH requirements for abuse reporting by the Regional RN to ensure understanding of reportable event timelines. The Abuse Policy was reviewed by the DON with no revisions required. The Administrator/designee will complete weekly audits x 3 months of all allegations of abuse and Resident to Resident altercations to ensure timely reporting to the NYS DOH as applicable. The Administrator/designee will report the results of the audits to the monthly QAPI committee for review and input. Responsible Party: Administrator

FF11 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: May 3, 2021
Corrected date: June 7, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY 451 and NY 008) completed on 5/3/21, the facility failed to ensure sufficient nursing staff to provide nursing and related services and safety to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment. Specifically, 5/1/21 to 5/2/21, during the 11:00 PM to 7:00 AM Shift: unit 4's staffing was 1 Licensed Practical Nurse (LPN) and 1 Certified Nurse Aide (CNA) for 53 residents. Resident #1, who is care planned for extensive assistance of 2 staff for bed mobility and hygiene with toileting, was observed at 6:14 AM in a bed with soiled linen. CNA #1 entered the resident room at 6:52 AM and exited room at 7:01 AM with soiled linens. LPN #1 was observed working at the medication cart during this time. Two staff assistance was not provided due to insufficient staffing. On 5/1/21, 3:00 PM to 11:00 PM staffing was 1 Registered Nurse (RN) and 2.5 CNAs. On 5/2/21, 11:00 PM to 7:00 AM shifts staffing was 1 LPN and 1 CNA for 53 residents. Resident #2 who is care planned for 1:1 observation at all times was observed multiple times on 5/1/21 (4:30 PM to 7:00 PM) and 5/2/21(6:00 AM to 12:30 PM) wandering the hallways, in common areas with other residents, and in the resident's room with the corridor door closed without 1:1 supervision. Resident #2 has been involved in resident to resident altercations alleging sexual abuse as recently as (MONTH) 2021. Resident #3, with a history of exit seeking behaviors, care planned for supervision when ambulating in hallways, pulled a fire alarm on 5/1/2021 and eloped from building at approximately 9:30 AM. Resident was found in the parking lot. This was widespread with no actual harm that is immediate jeopardy to resident health and safety. The findings are: The policy and procedure (P&P) titled Emergency Staffing dated 3/2020 documented the facility should request all nursing administration staff to be available and ready to provide ADL (activities of daily living) care to supplement the CNAs. The facility P&P titled Care Plans - Comprehensive with revision date 10/2019 documented the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility P&P titled Supervision 1:1 dated 12/2019 documented 1:1 is determined necessary when a resident's safety risk cannot be appropriately monitored through frequent supervision or the Resident is in danger of injuring themselves or another resident. 1. The Facility Assessment Portfolio (used to determine resources necessary to care for facility residents competently during both day-to-day operations and emergencies) dated (MONTH) 2020, documented a bed capacity of 200 with an average daily census of 181. The required staffing was documented as the following: 2nd floor bed capacity 60: -LPNs: 3 for the day shift (7:00 AM - 3:00 PM). 3 for the evening shift (3:00 PM -11:00 PM); 2 for the night shift (11:00 PM - 7:00 AM). -CNAs: 6 for the day shift; 6 for the evening shift; 3 for the night shift. 3rd floor bed capacity 80: -LPNs: 3 for the day shift; 3 for the evening shift; 2 for the night shift. -CNAs: 8 for the day shift; 6 for the evening shift; 4 for the night shift. 4th floor bed capacity 60: -LPNs: 2 for the day shift; 2 for the evening shift; 1 for the night shift. -CNAs: 6 for the day shift; 4 for the evening shift; 3 for the night shift. The facility Midnight Census Report dated 4/30/21 documented a census of 169. The actual staffing for the 5/1/21 7:00 AM to 3:00 PM shift was 6 LPNs and 15 CNAs (down 2 LPNs and 5 CNAs); the 3:00 PM to 11:00 PM shift was 5 LPNs and 11 CNAs (down 3 LPNs and 5 CNAs). The facility Daily Census dated 5/1/21 documented a census of 170 residents. The actual staffing for the 5/1/21 11:00 PM to 7:00 AM shift was 5 LPNs and 3 CNAs (down 7 CNAs); the 5/2/21 7:00 AM to 3:00 PM shift was 5 LPNs and 11 CNAs (down 3 LPN's and 9 CNAs). The scheduled staffing for the 5/2/21 3:00 PM to 11:00 PM shift was 3 LPNs, 8.5 CNAs (down 5 LPN's and 7.5 CNAs). During an interview on 5/2/21 at 6:22 AM, RN #1 the 11:00 PM to 7:00 AM Nursing Supervisor, stated each unit is typically staffed with one LPN and one CNA for the night shift. RN #1 stated there have been shifts when only one LPN was scheduled for the entire building and staffing is horrible here. During an interview on 5/2/21 at 6:34 AM, the third floor 11:00 PM to 7:00 AM LPN #3 stated resident care and incontinent care are not sufficiently nor provided timely to residents because there is not enough staff. LPN #3 stated residents complain that they were not even touched on the 3:00 PM to 11:00 PM shift. During an interview on 5/2/21 at 6:43 AM, the second floor LPN #4 stated it was impossible to pass medications and assist the CNA with resident care. During an interview on 5/1/21 at 5:20 PM, the third floor 3:00 PM to 11:00 PM CNA #2 stated residents were not transferred out of bed to eat dinner because there was not enough staff. During an interview on 5/1/21 at 5:22 PM, the third floor 3:00 PM to 11:00 PM CNA #3 stated incontinent care was not always provided timely to residents' because there was not enough staff. 2. The facility's Daily Census dated 5/1/21 documented 53 residents resided on the fourth floor, a designated dementia unit. The untitled facility daily nursing schedule, provided by the 11:00 PM to 7:00 AM Registered Nurse (RN) Supervisor #1, dated 5/1/21, documented one LPN and one CNA were scheduled to work on the fourth floor for the 11:00 PM to 7:00 AM shift. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 2/26/21 documented the resident was usually understood, sometimes understands, and had moderate cognitive impairment. The MDS documented the resident required extensive physical assist of two people for bed mobility and toilet use. Resident #1's Visual/Bedside Kardex Report (guide used by CNAs to provide care), dated 5/2/2021, documented extensive assistance of two staff members for bed mobility and total dependence of two staff members for toileting. During an observation on the fourth floor 5/2/21 at 6:14 AM Resident #1 was lying in bed on soiled linens wearing an incontinent brief and a soiled gown. The resident was covered in a foul smelling yellow/brown liquid like substance from their head to their knees. There were areas of this foul-smelling substance drying on the linens. At 6:52 AM CNA #1 entered Resident #1's room, while LPN #1 was observed at the medication cart. CNA #1 exited Resident #1's room at 7:01 AM with dirty linens. LPN #1 did not enter Resident #1's room during this observation. During an interview on 5/2/21 at 6:19 AM, CNA #1 stated they were the only CNA on the fourth floor for the 11:00 PM to 7:00 AM shift and there was one LPN. The CNA #1 also stated they were unable to provide care to the fourth-floor residents as care planned. During an interview on 5/2/21 at 6:25 AM, LPN #1 stated there was only nurse on the fourth floor for the 11:00 PM - 7:00 AM shift and there was one CNA. The LPN #1 stated they assisted the CNA as much as possible, but the LPN was responsible for medications and treatments, and were not always available to assist. During an interview with CNA #1 on 5/2/21 at 7:01 AM the CNA #1 stated, incontinent care was provided for Resident #1. The CNA #1 was aware Resident #1 required extensive assistance of two staff for incontinent care, but was the only CNA working on the unit, making it impossible to provide the care planned level of assist for Resident #1. During an interview with the Administrator on 5/2/21 at 3:26 PM the Administrator stated, the expectation was for care to be provided per the resident's care plan. If there was only one CNA scheduled on a unit, he would expect staff from another unit to assist. 3. The facility's Daily Census dated 5/1/21 documented 53 residents resided on the fourth floor, a designated dementia unit. The untitled, 5/1/21 staffing sheet for the 3:00 PM to 11:00 PM shift documented one LPN and two CNA's with an additional CNA scheduled to come in at 8:00 PM as the actual working schedule for the fourth floor. The untitled, 5/2/21 staffing sheet for the 7:00 AM to 3:00 PM shift, handwritten by the facility Administrator documented one LPN and three CNA's as the actual working schedule for the fourth floor. Resident #2 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was usually understood, sometimes understands, and had moderate cognitive impairment. Resident #2's comprehensive care plan (CCP) dated 1/29/21 documented the resident was placed on a 1:1 ATC (around the clock) because the resident lacked capacity to consent to sexual contact and had possible sexual contact with peer resident. During an observation on the fourth floor 5/1/21, from 4:48 PM to 5:57 PM, and on 5/2/21 from 6:05 AM to 12:00 PM Resident #2 was wandering independently in the hallways, in the common area with other residents, and in their room without 1:1 supervision. During an interview on 5/1/21 at 5:13 PM, the fourth floor 3:00 PM to 11:00 PM CNA #4 stated Resident #2 required 1:1 supervision, but staff was unable to provide 1:1 supervision. During an interview with CNA #1 (fourth floor 11:00 PM to 7:00 AM) on 5/2/21 at 6:19 AM. CNA #1 stated they were unable to provide 1:1 for Resident #2 throughout their shift. During an interview on 5/2/21 at 6:25 AM, the fourth floor 11:00 PM to 7:00 AM LPN #1 stated, Resident #2 required 1:1 supervision around the clock and LPN #1 was unable to provide 1:1 for Resident #2 during their shift. During an interview with LPN #2 on 5/2/21 at 12:00 PM, LPN #2 stated, they were the only nurse scheduled on the fourth floor with 3 CNAs for the 7:00 AM to 3:00 PM shift. LPN #2 stated there was not enough staff to provide 1:1 supervision for Resident #2 while providing care to other residents on the unit. During an interview on 5/2/21 at 3:26 PM, the Administrator stated, residents on 1:1 supervision require staff to be nearby the resident and have the resident within eyesight. 4. The facility's Midnight Census Report dated 4/30/21 documented 53 residents resided on the fourth floor, a designated dementia unit. The untitled facility daily nursing schedule dated 5/1/21, documented two LPNs and five CNAs were scheduled to work the fourth floor on the 7:00 AM to 3:00 PM shift. Resident #3 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was sometimes understood, sometimes understands, and was cognitively intact. The MDS documented the resident required supervision for walking in the corridor. Resident #3's Visual/Bedside Kardex Report dated 5/2/21 documented they ambulated in the corridor with supervision. The Facility 24 Hour Report documented Resident #3 had exit seeking behaviors on 4/14/21, 4/15/21, 4/18/21, 4/20/21, 4/23/21, and 5/1/21. The RN Assessment dated 5/1/21 documented at 9:15 AM Resident #3 was observed wandering the hallways on the 4th floor, pushing at fire exit doors, checking doorknobs, and attempted to pull the fire alarm multiple times. At 9:30 AM the fire alarm triggered. During an observation of the fourth floor on 5/2/21 between 6:10 AM and 10:20 AM Resident #3 was ambulating unsupervised in the 4th floor corridor. At 10:20 AM the resident triggered the delayed egress on the C-Hall and no staff responded. During an interview on 5/2/21 at 9:58 AM, maintenance worker #1 stated the fire alarm pull station on the fourth floor C-Hall triggered on 5/1/21 at 9:20 AM and Resident #3 went down the stairwell. During an interview on 5/2/21 at 10:34 AM, the Food Service Director (FSD) stated the fire alarm sounded on 5/1/21 at approximately 9:30 AM and a staff member (Housekeeper #1) alerted the FSD that a resident was alone, ambulating in the parking lot. The FSD immediately went outside and brought Resident #3 back into the building. During an interview with the Director of Nursing (DON) on 5/2/21 at 11:04 AM the DON stated, they were unaware Resident #3 had eloped (left) from the building on 5/1/21. During an interview on 5/2/21 at 12:39 PM, the DON stated the expectation was that resident care be provided per the care plan. If a unit did not have enough staff to provide resident care per the care plan, staff was expected to assist from other units. During an interview on 5/2/21 at 3:26 PM, the Administrator stated there was no minimum staffing P&P and there needed to be sufficient staff to meet the needs of the residents. The Administrator stated the building was sufficiently staffed as evidenced by no negative outcomes. During an interview with the Administrator on 5/3/21 at 1:28 PM the Administrator stated, they were unaware of the staffing issues in the building. 10NYCRR415.13 (a)(1)(i-iii)

Plan of Correction: ApprovedMay 28, 2021

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-725 483.35(a)(1)(2) Sufficient Nursing Staff ?§483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. ?§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. ?§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. Resident # 1 remains in the facility with no adverse effects from care provided by CNA #1 on 5/2/21. Resident # 2 remains in the facility with no adverse effects from lack of supervision cited on 5/2/21. Resident # 3 was discharged to hospital on [DATE] and has not returned to the facility. LPN # 1, # 2 and CNA # 1 and #4 were counseled by the DON regarding importance of following resident specific care plans including 1 to 1 supervision as indicated. RN Supervisor # 1 was counseled by the DON regarding facility elopement and investigation policies & procedures. The FSD and Housekeeper # 1 were counseled by the DON regarding the need to immediately report resident elopement to the Nursing Supervisor. The QAPI Committee met on 5/2/21 and minimum staffing numbers were established based on facility census and resident acuity; numbers will be reviewed and revised by the QAPI Committee as indicated. Direct care staff were scheduled to meet established minimums. Bonuses were offered to all CNA/LPN staff as well as contracted agency staff to meet minimal numbers. Staff from sister facilities were reassigned to facility as needed. A protocol for critical staffing was established; if minimum numbers are not met- the Administrator or DON will be notified, Nursing Administrative and Ancillary staff will be reassigned to fill needs as indicated. Recruitment efforts continue including ongoing advertising for open positions, sign on bonuses for specific positions and contracted staffing agencies. Facility policies including Staffing, Emergency Staffing. 1:1 care, elopement prevention and Comprehensive Care Plans were reviewed by the Corporate Director of Education & Clinical Practice with no revisions required. The Nursing Staffer in place at the time of the noted citations has been replaced. Direct care staff were re-educated by the RN Educator regarding ensuring that resident care plans/Kardex are followed including supervision for 1:1 residents, fire alarm response protocols and notifying Administrator/designee of staffing below minimums. All staff that did not receive education (time off, not scheduled, etc) were re-educated before being allowed to work. The RN Regional Nurse/RN Educator will re-educate all Nursing staff and direct line staff regarding the policies and protocols relating to staffing, Emergency Staffing,1:1care, elopement prevention, fire alarm Response and Comprehensive Care plans. Facility will establish a Recruitment/Retention Committee; this Committee will meet bi-weekly and will explore ways to enhance staffing such as job fairs, flexible shifts, etc. Facility will establish Time & Attendance protocols to include counseling and progressive discipline for excessive absenteeism. The Administrator/designee will review staffing daily to ensure that staffing numbers are adequate to meet resident needs. 10 Weekly random audits on all shifts will be conducted by the RN The Nursing Administrative team, including Nursing Supervisors were re-educated on the critical staffing protocol. The Facility Assessment will be updated. Educator/designee to ensure CNA Kardex and individualized resident care plans are being followed. Fire alarm and elopement drills will be conducted monthly x 3. Any issues identified will be immediately addressed. The results of the daily Administrator/designee reviews ,RN Educator audits, Recruitment/Retention Committee meeting minutes and elopement/fire alarm response drills will be reported to the QAPI Committee for review and input. The Administrator is responsible for this correction.