The Plaza Rehab and Nursing Center
February 11, 2019 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: February 11, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's surveillance camera, staff interviews, and record review conducted during an abbreviated survey (Complaint #NY 310), the facility did not ensure that a resident was free from staff abuse. This was evident in 1 out of 3 residents sampled for physical abuse (Resident #1). Specifically, on 03/07/2018 Resident #1 and Certified Nursing Assistant #1 (CNA #1) were observed on camera, engaged in a verbal exchange. Resident #1 hit CNA #1, and the CNA retaliated and hit Resident #1 back. The Findings are: The facility's Policy and Procedure titled Resident Abuse, Mistreatment, and Neglect revised on 04/23/18 documented that the facility has a zero-tolerance policy regarding abuse. Abuse can include verbal, mental, sexual or physical abuse, neglect, misappropriation of property, exploitation, mistreatment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are at the facility. The policy indicates that physical abuse includes hitting, slapping, punching, biting and kicking. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 02/14/2018 documented that Resident #1 had a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) and scored 15/15 (00-07 severe impairment, 08-12 moderate impairment & 13-15 intact cognition). Review of the Comprehensive Care Plan (CCP) dated 02/24/2018, revealed that Resident #1 was a potential risk for abuse due to aggressive behavior; risk to abuse others, verbally, aggressive, abusive behavior, and poor impulse control. The interventions included monitoring and documenting unusual behavior; assisting the resident to develop a familiar/trusting relationship and redirect any unacceptable behavior. Review of the Behavioral CCP dated 02/02/2018 revealed that Resident #1 had mood fluctuations. Resident #1 was on [MEDICAL CONDITION] medications as evidenced by being verbally abusive, physically abusive, aggressive and destructive behavior. The interventions included identifying a pattern of behavior, redirecting negative behaviors, allowing time to deescalate and re-approach if agitated. Review of the Nursing Assistant Accountability Record for 02/2018, revealed that there were no instructions on how CNAs should respond to Resident #1's aggressive, verbally abusive and poor impulse control behavior. Review of the facility's surveillance camera revealed that at 4:35 PM, three nursing staff members were observed at the nursing station. Two of the staff were sitting inside of the nursing station while one was standing outside of the nursing station. Resident #1 was observed in the corridor close to the nursing station sitting in his wheelchair. Other residents were also observed sitting around at the nursing station. Resident #1's mouth and hands kept moving. Another resident was also sitting across from Resident #1. The other resident was also engaged as noted by his hand gestures. At 4:37 PM, CNA #1 and CNA #2 were observed chatting, and CNA #1 walked away from the nursing station. Resident #1 was still in the corridor near the nursing stating with his back turned to the nursing station. At 4:38 PM, CNA #1 returned to the nursing station and stood at the entrance of the nursing station. She was communicating with CNA #2 who walked away leaving a nursing staff sitting on the inside of the nursing station and CNA #1 standing outside of the nursing station at the entrance. Resident #1 turned his wheelchair around; now engaged in a conversation with CNA #1. As they continued to engage, CNA #1 walked over to the other section of the nursing station where she was now closer to Resident #1. Resident #1 moved his wheelchair closer to CNA #1 as they continued to engage. Resident #1 first attempted to hit CNA #1, but she did not walk away or attempted to distance herself from Resident #1. Resident #1 made a second attempt to hit CNA #1 and his right hand connected with the right side of the CNA's head. CNA #1 reached overextended her right arm with an open palm and hit (appeared with force) Resident #1 on his right shoulder. CNA #2 held CNA #1 from behind, Resident #1 stood up from his wheelchair, and CNA #2 stood in between CNA #1 and Resident #1. Another staff appeared in the nursing station and attempted to intervene. The nurse that was sitting in the nursing station was still seated during the incident. The staff that was at the nursing station during the verbal exchange between Resident #1 and CNA #1 did not intervene until the incident became physical. Review of the Nurse's Progress Note dated 03/07/2018 documented that CNA #1 told Resident #1 to stop playing dirty Music and Resident #1 punched CNA #1 on the right side of her face. The resident flung a bottle of water at the staff, and it landed on another resident's left arm. Other Staff intervene and called security for safety. Facility physician was notified, and Resident #1 was ordered to be sent out of the facility. Review of the Social Worker's Progress Note dated 03/07/2018 documented that Resident #1 claimed that staff hit him, and he hit staff back, however security guard reported that it was the resident who hit the staff first and CNA #1 retaliated back. Review of the Physician's Progress Note dated 03/08/2018 documented that Resident #1 was transferred to the Hospital for agitation and assaulting an employee by slapping her. It further revealed that Resident #1 was observed in the emergency room (ER) overnight and was transferred back to the facility. A facility Official Warning Notice document dated 03/09/2018, revealed that CNA #1 was engaged in an altercation with Resident #1. Resident #1 hit CNA #1, and the CNA retaliated and hit Resident #1. A facility Administrative Determination of the incident document, dated 03/12/2018, revealed that the facility concluded that there was no cause to believe that abuse, exploitation or neglect of Resident #1 had occurred. New York State Department of Health was not notified. CNA #1 was interviewed on 01/29/2019 at 1:15 PM and denied the incident that was observed on the facility's surveillance camera. She stated that she was sitting on a chair and she asked Resident #1 to stop playing vulgar music and that Resident #1 hit her. She denied hitting Resident #1. The Registered Nurse (RN), who created Resident #1's plan of care, was interviewed on 01/29/2019 at 12:30 PM and stated that there was no need to put instructions on the Accountability Record for the CNAs as Resident #1 did not manifest any combative behavior until 03/07/2018. CNA #2 was interviewed on 01/29/2019 at 11:49 AM and stated that she saw Resident #1 shouting and moving towards CNA #1, while CNA #1 was standing at the nurse's station. Resident #1 was in his wheelchair, and he hit CNA#1. It was too fast; I just saw CNA#1 pushed Resident #1 fast. CNA #1's hand was on Resident #1, but she was unable to determine if CNA #1 hit or push Resident #1. A few seconds after the incident, the Resident became aggressive; shouting; stood up and was going towards CNA #1. She tried to stop Resident #1, and CNA #1 and the LPN paged Code Gray. The Assistant Director of Nursing (ADON) was interviewed on 01/29/2019 at 4:10 PM and stated that she went to the unit immediately after she heard Code Gray. She saw Resident #1 attempted to hit CNA #1 with a bottle and the bottle landed towards another resident. She did not witness the entire incident. The resident was aggressive towards the staff and 911 was called. She did not watch the facility surveillance video. 415.4(b)(1)(I)

Plan of Correction: ApprovedFebruary 22, 2019

F600: Abuse

Resident # 1-(NAME)Alford

I.Plan of correction for affected residents
-Resident ID # 1 Assessed for injury, none noted. Psychiatry consult was reviewed. Care Plan updated to reflect interventions to manage escalating behaviors.
II. Plan to identify other residents potentially affected by this deficiency
- Facility progress notes audited for the past 30 days for keywords that indicate events potentially requiring investigation and/or reporting.
- Identified events will be reported accordingly.
- Progress note authors of identified unreported events educated as appropriate.

III. System changes and measures to prevent recurrence

- Abuse, Neglect, Mistreatment and Exploitation policy reviewed and determined to be in compliance with State and Federal regulations
- All staff will be re-educated on Abuse prohibition
- Nursing staff will be educated on identifying escalating behaviors, behavioral triggers and early intervention.
- Residents with behavior that places self and others at risk will be reviewed by IDT at risk meeting when identified.

IV. Plan to monitor effectiveness of corrective actions
- 100% of residents with behavior that places self and others at risk will be audited for individualized care plan for behaviors and/or triggers weekly x 4 then monthly x 3 months
- Audit finding will be submitted to the QAPI committee monthly for review and recommendations.
Director of Nursing/ Designee will be responsible for monitoring compliance.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 11, 2019
Corrected date: April 16, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's surveillance camera, staff interviews, and record review conducted during an abbreviated survey (NY 310), the facility did not ensure that a staff-to-resident physical altercation was thoroughly investigated and reported to New York State Department of Health (NYSDOH). This was evident in 1 out of 3 residents sampled for staff abuse (Resident #1). Specifically, on 03/07/2018 Resident #1 and Certified Nursing Assistant #1 (CNA #1) were observed on the surveillance camera, engaged in a verbal and physical altercation. The facility did not interview Resident #1, did not review the facility's surveillance camera and did not report the altercation to NYSDOH. The Findings are: The facility's Policy and Procedure titled Resident Abuse, Mistreatment, and Neglect revised on 04/23/18 documented that the facility has a zero-tolerance policy regarding abuse. Residents will be protected from abuse, neglect, and harm while they are resident at the facility. Law Enforcement and State Agency would be notified as indicated. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 02/14/2018 documented that Resident #1 had a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) and scored 15/15 (00-07 severe impairment, 08-12 moderate impairment & 13-15 intact cognition). Review of the Nurse's Progress Note dated 03/07/2018 documented that CNA #1 told Resident #1 to stop playing dirty Music and Resident #1 punched CNA #1 on the right side of her face. The resident flung a bottle of water at the staff, and it landed on another resident's left arm. Other Staff intervene and called security for safety. Facility physician was notified, and Resident #1 was ordered to be sent out of the facility. Review of the facility's Occurrence Report dated 03/07/2018 at 4:35 PM, revealed that Resident #1 was reported to have an aggressive behavior towards a staff member. Resident #1 was playing vulgar music in the hallway by the nursing station in the presence of other residents. CNA #1 asked Resident #1 to turn low the volume of the music. Resident #1 became aggressive and violent against CNA #1. Resident #1 threw a bottle that hit another resident. Resident #1 was sent out to the Hospital for evaluation and staff was taken off the unit. There were no harm or injury noted to any of the residents. Review of the facility's surveillance camera revealed that at 4:35 PM, three nursing staff members were observed at the nursing station. Two of the staff were sitting inside of the nursing station while one was standing outside of the nursing station. Resident #1 was observed in the corridor close to the nursing station sitting in his wheelchair. Other residents were also observed sitting around at the nursing station. Resident #1's mouth and hands kept moving. Another resident was also sitting across from Resident #1. The other resident was also engaged as noted by his hand gestures. At 4:37 PM, CNA #1 and CNA #2 were observed chatting, and CNA #1 walked away from the nursing station. Resident #1 was still in the corridor near the nursing stating with his back turned to the nursing station. At 4:38 PM, CNA #1 returned to the nursing station and stood at the entrance of the nursing station. She was communicating with CNA #2 who walked away leaving a nursing staff sitting on the inside of the nursing station and CNA #1 standing outside of the nursing station at the entrance. Resident #1 turned his wheelchair around; now engaged in a conversation with CNA #1. As they continued to engage, CNA #1 walked over to the other section of the nursing station where she was now closer to Resident #1. Resident #1 moved his wheelchair closer to CNA #1 as they continued to engage. Resident #1 first attempted to hit CNA #1, but she did not walk away or attempted to distance herself from Resident #1. Resident #1 made a second attempt to hit CNA #1 and his right hand connected with the right side of the CNA's head. CNA #1 reached overextended her right arm with an open palm and hit (appeared with force) Resident #1 on his right shoulder. CNA #2 held CNA #1 from behind, Resident #1 stood up from his wheelchair, and CNA #2 stood in between CNA #1 and Resident #1. Another staff appeared in the nursing station and attempted to intervene. The nurse that was sitting in the nursing station was still seated during the incident. The staff that was at the nursing station during the verbal exchange between Resident #1 and CNA #1 did not intervene until the incident became physical. A facility Official Warning Notice document dated 03/09/2018, revealed that CNA #1 was engaged in an altercation with Resident #1. Resident #1 hit CNA #1, and the CNA retaliated and hit Resident #1. A facility Administrative Determination of the incident document, dated 03/12/2018, revealed that the facility concluded that there was no cause to believe that abuse, exploitation or neglect of Resident #1 had occurred. New York State Department of Health was not notified. The Assistant Director of Nursing (ADON) was interviewed on 01/29/2019 at 4:10 PM and stated that she went to the unit immediately after she heard Code Gray. She saw Resident #1 attempted to hit CNA #1 with a bottle and the bottle landed towards another resident. She did not witness the entire incident. The resident was aggressive towards the staff and 911 was called. She conducted the investigation; wrote the investigation summary report and made the administrative determination. She did not watch the facility's surveillance video; there was no indication to review it. Resident #1 was aggressive towards the staff, and he was harmful to himself and others. She did not interview Resident #1, and the incident was not reported to NYSDOH. The Director of Nursing and the Administrator, who were in the facility's employment at the time of the incident, were not interviewed as they were unreachable. 415.4 (b)

Plan of Correction: ApprovedFebruary 22, 2019

F610: Investigate/Prevent/ Correct Alleged Violations

I. Plan of correction for affected residents
- Resident # 1 transferred to the hospital for evaluation, returned without admission, no ill effects or injury and remains in the facility to date.
- CNA # 1 terminated effective 3/09/2018.
II. Plan to identify other residents potentially affected by this deficiency
-Audit conducted of all altercations 3/8/2018 to present to ensure resident interview conducted, review of surveillance where and when available and reportability to NYS DOH.
III. System changes and measures to prevent recurrence
- All staff educated on Abuse prohibition and reporting requirements.
- Incident report revised to include resident statement/interview.
- Risk management meeting implemented to review all incidents weekly.
IV. Plan to monitor effectiveness of corrective actions and ongoing
- Incident reports will be audited to ensure presence of resident interview, review of surveillance where and when available, and reportability to NYS DOH as required weekly x 4 then monthly x 3.
- Audit findings will be report to QAPI committee for review and recommendation monthly.

Director of Nursing/ Designee will be responsible for monitoring compliance.