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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 8, 2023
Corrected date: March 27, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY 797) the facility failed to ensure that all allegations of abuse, neglect and mistreatment were thoroughly investigated. In addition, the facility failed to ensure the residents were free from further potential abuse. This was evident for one (Resident #1) of 7 residents reviewed for Sexual Abuse. Specifically, on 12/10/2022 Resident #1 reported to their family that Licensed Practical Nurse (LPN)#I on 12/9/2022 asked them to perform oral sex and then proceeded to touch their breast and vaginal area. The resident's family reported the incident to the Administrator on 12/10/2022. LPN #I continued to work in the facility and had access to the resident on 12/11/2022. As of 1/6/2023 the facility did not initiate an investigation. This resulted in potential abuse and harm to Resident #1 other residents that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility's policy titled Abuse revised 5/2022 documented it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. When any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed, reported or suspected by any employee ensure the resident is no longer being provided care and does not have any contact with the accused employee. Notify administrative staff or nursing supervisor on duty. Suspend or reassign the employee pending investigation. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS-an assessment tool) dated 10/19/2022 documented the resident with Brief Interview for Mental Status score of 9 indicating moderately impaired cognition. The Comprehensive Care Plan dated 10/13/2022 documented the resident has potential for impaired cognition. Interventions included monitor for cognitive changes or regression and report to the nurse and reorient as needed. The notes dated 10/13/022 documented the resident is able to make basic needs known. Review of Accident/Incident (A/I) reports and Grievances for (MONTH) 2022 revealed no documented evidence of an investigation related to allegation on 12/9/2022 or 12/10/2022. Review of the progress notes dated 12/10/2022 to 1/6/2023 revealed no documented evidence of a resident assessment or investigation related to the 12/9/2022 or 12/10/2022 sexual abuse allegation. A review of staffing sheets dated 12/8/2022 and 12/10/2022 documented LPN #1 was scheduled during 7:00 AM-3:00 PM shift as Unit Manager for the 1st and 2nd floor. LPN #1 was not scheduled to work on 12/9/2022. Review of the progress notes dated 12/11/2022 at 2:44 AM documented the resident was transferred to 1st floor. A review of staffing sheets revealed LPN #1 was scheduled to work on 12/11/2022 during 7:00 AM-3:00 PM shift for the 1st and 2nd floor. Review of the care plans revealed no documented evidence that the resident was care planned for abuse as victim. The care plan was updated on 12/18/2022 and included risk for abuse. The care plan notes revealed no documented evidence it was updated related to 12/9/2022 or 12/10/2022 sexual abuse allegation. During an interview with Resident #1 on 1/4/2023 at 12:38 PM they stated they were touched by a staff member identified as LPN #1. Resident #1 stated they could not recall the date, but it was dark, and it happened in their room. Resident #1 stated, LPN #1 went under my clothes and touched my breast and tried to make me suck their dick. Resident #1 further stated they told LPN #1 they were going to call the Police and LPN #1 stopped and left the room. Resident #1 stated they told their family member #1 the next day. Resident #1 was unsure of the date and time of the incident. Resident #1 stated they did not want this to happen again and stated they don't feel safe. During a telephone interview on 1/4/2023 at 2:23 PM with Resident #1's family member #1 they stated that Resident #1 reported to them on 12/10/2022 during a home visit that on 12/9/2022 LPN #1 touched their breast and vaginal area and asked them to perform oral sex. Family member #1 stated they reported the incident to the Administrator on 12/10/2022 at approximately 9:00 PM-10:00 PM. They stated that the Administrator stated they will conduct an investigation and LPN #1 will be suspended. The family member #1 stated that the Administrator stated they will not report the incident to the Department of Health (DOH) because there was no proof. The family member #1 stated they saw LPN #1 on 12/11/2022 working in the facility They stated they brought Resident #1 to the Police station on 12/19/2022 to report the incident. The facility did not report the incident to the police because there was no police report. The family member #1 stated that a care plan meeting was held on 12/29/2022 with the facility and Ombudsman #1 regarding the incident and the Administrator did not report the allegation citing there was no proof. During an interview with the Administrator on 1/4/23 at 3:39 they stated that on 12/10/2022 they received a call at approximately 8:00 PM from the family of Resident#1. The family reported an allegation that an unnamed staff inappropriately touched Resident #1. The family identified the staff as LPN #1 because they wheeled Resident#1 down to the lobby to go out on pass on 12/10/2022. The Administrator stated they contacted the Director of Nursing (DON) on 12/10/2022 and informed them of the allegation. The Administrator stated they reviewed the video surveillance on their cellphone on 12/10/2022 and based on video there was no sexual, or any inappropriate touching or physical contact. The Administrator stated the allegation was not reported to DOH or the police because they had no finding that abuse occurred. The Administrator stated they report incidents if there is an allegation of abuse and if abuse occurred. During an interview with the DON on 1/4/2023 at 4:21 PM they stated they were not aware of any allegation of abuse involving Resident #1 and LPN #1 on 12/9/2022 or 12/10/2022. The DON stated they received a call from the administrator on 12/10/2022 and was instructed to move to Resident#1 to the 1st floor because of infection control concerns. The DON stated they first learned about the allegation during a meeting with Ombudsman #1 on 12/29/2022. The DON stated they did not do an investigation or report the allegation to the police. The DON was not aware of the facility's policy on abuse reporting and stated they have to read the policy. During an interview with the Director of SW (DSW) on 1/6/2023 at 10:08 AM they stated that Police came to the facility on [DATE] and informed them that Resident #1's family filed a report regarding inappropriate sexual contact with a staff member. The DSW stated they immediately informed the administrator and they spoke to the Police. DSW stated they spoke to Resident #1 and the resident did not say much regarding the allegation. DSW did not document their interview with the resident or the Police inquiring about an allegation. DSW was told by the Administrator that the allegation was unfounded. During an interview with the Ombudsman #1 on 1/5/2023 at 11:33 AM they stated they were made aware of the allegation of inappropriate sexual contact between LPN #1 and Resident#1 on 12/22/2022 by the family member who called their program. The Ombudsman #1 stated they went to the facility on [DATE] and spoke with the Administrator about the allegation on 12/9/2022 and they stated that they did not report it to the DOH because the resident could not tell them what happened, and they had no proof. The Administrator stated they checked the video and did not find any proof. The Ombudsman #1 spoke to the resident on 12/22/2022 and resident reported that LPN #1, mentioning them by their name, touched them in their breast and over their vaginal area with their finger in a thrusting manner. Resident #1 did not say they were penetrated but was pointing to their vaginal area. The video surveillance was reviewed on 1/5/2023 at 12:55 PM and on 1/6/2022 at 10:45 AM with the Administrator and the Staffing Coordinator. Review of 1st floor video on 12/11/2022 at 12:38 PM revealed Resident #1 was taken out of the room by RNS #1. On 12/11/2022 hallway camera revealed LPN #1 punched in at 7:00:14 AM and took the elevator and was observed sitting at the 2nd floor nursing station. The LPN #1 was then observed going in and out of residents' rooms. During an interview with the Administrator on 1/5/2023 at 1:58 PM they stated there is no investigation being conducted at this time. The Administrator stated they had no findings that the allegation actually happened to support suspending LPN #1. They moved Resident #1 from the 2nd floor to the 1st floor because of the allegation. The Administrator denied speaking to the police on 12/21/2022 and was not informed that there was an allegation involving LPN #1. During interviews conducted between 1/5/2023 at 2:30 PM to 1/6/2023 at 5:16 PM with LPN #2, LPN #3, Certified CNA #1, RNS #1, CNA #2, RNS #2, CNA #4 and LPN #4, who all worked between 12/8/2022 to 12/11/2022 on various shift, stated that they were not aware of the allegation involving Resident #1 and LPN #1 and they were not questioned by the facility or asked to write a statement. During an interview with the DON on 1/5/2023 at 2:59 PM they stated that there is no investigation conducted related to the allegation involving LPN #1 and Resident#1. The DON stated they initiated the investigation on 1/4/2022 and wrote down in the paper the interview conducted with Resident #1. Resident #1 stated a white, male staff, identifying LPN #1 by their name, pulled out their private area and asked Resident #1 perform oral sex. Resident #1 did not state a date, Resident #1 said it was light outside not dark when LPN #1 went in the room. The DON stated the resident denied any physical contact. The DON stated no other staff were interviewed at this time. The DON stated they were not aware that Police came to the facility and reported a family member filed a report of the allegation against LPN #1. During a subsequent interview conducted with the Administrator on 1/6/2023 at 10:00 AM they stated that they did not interview other staff because based on video there was no evidence of inappropriate sexual contact. The administrator stated they were not aware of the facility's policy on abuse reporting and investigation. During a telephone interview with LPN #1 on 1/6/2023 at 11:07 AM stated they worked on 12/11/22 on the 2nd floor and were assigned to Resident #1. LPN #1 stated they last worked on 12/11/2022 and they were off on 12/9/22. LPN #1 stated they brought Resident #1 sandwiches like anyone else and encouraged resident to use their left hand more. LPN #1 stated they are on leave of absence. LPN #1 stated they are not aware of any sexual allegation involving them. LPN #1 stated they have not been interviewed or asked to write a statement. LPN #1 stated they did not touch Resident #1 on their breast or vaginal area. LPN #1 stated they did not show Resident #1 their private area and did not ask Resident #1 to perform oral sex. LPN #1 was not aware of any allegation against them and was not restricted from going to the first floor. During an interview with ADON on 1/10/2023 at 2:41 PM they stated that all allegations of abuse are handled by DON. ADON stated the DON informed them sometime in mid-December that Resident #1 was touched inappropriately by a staff, but DON did not know which staff. ADON stated they assumed the DON and Administrator was handling the investigation. ADON stated the allegation was not discussed in the morning report. 10 NYCRR 415.4 b (3)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during post survey revisit for complaint number NY 797 completed on 3/8/2023 the facility did not ensure that fall occurrences were thoroughly investigated to rule out abuse, neglect, or mistreatment for [REDACTED]. Specifically, the facility concluded the six A/I report ruled out abuse, neglect or mistreatment without obtaining statements or interviews from the relevant staff and witnesses to the incident. The finding is: The facility's policy titled Accident/Incident (A/I) revised 10/13/22 defined accident as an unexpected event that can cause a resident bodily injury which included lacerations requiring suturing, fractures, second- or third-degree burns, concussion, or head injury with neurological changes. Incident is defined as unexpected, unintended event that can cause a resident superficial injury which included scratches, abrasions, blisters, ecchymosis areas, bruises, first degree burns, lacerations, superficial skin tears, hematoma and head injury without neurological changes. Occurrence is defined as any event or circumstance that is not consistent with the routine operation of the nursing facility or routine care of the resident. An occurrence is without any resulting injury, examples included falls without injury and reddened areas. An accident/incident/occurrence report must be prepared for all occurrences. The report must be initiated before the end of the shift on which it occurred. The nursing supervisor or charge nurse must be notified, must immediately investigate the accident/incident, and complete the A/I report form. The Charge nurse or RNS will obtain statement from the resident as applicable and from all relevant staff on duty utilizing the appropriate investigative reports. The Director of Nursing (DON) and the Administrator will review all accident/incident and occurrence reports for completeness, appropriateness and corrective measures. The facility's policy titled Abuse Prohibition and Prevention revised 1/26/23 documented the facility is responsible for prompt and thorough investigation of all alleged violations and occurrences. Upon completion of the investigatory process by authorized personnel, all facts and information shall be reviewed with the Administrator or designee. It is the policy of the facility that reports of abuse (mistreatment, neglect, abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Investigation will begin upon learning of a potential incident of abuse and the investigation will be completed within five business days. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary if any for the protection of residents. Depending upon the type of allegation received, it is expected that the investigation would include conducting observation, record review and interviews as appropriate with the alleged victim and representative, alleged perpetrator, witnesses, practitioner, interviews with personnel from outside agencies such as other investigatory agencies, and hospital or emergency room personnel. Clinical staff shall utilize the occurrence/incident report and immediately notifies the Director of Nursing and/or Administrator for any alleged violations. 1) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data set (MDS - an assessment tool) dated 12/7/22 documented the resident with Brief Interview for Mental status (BIMS) score of 10 indicating moderately impaired in cognition. The resident required extensive assistance of one person for bed mobility, transfer, and locomotion. Resident #2's Occurrence report dated 2/26/23 at 10:40 PM documented that Resident#2 was sitting in a wheelchair at the nursing station, stood up and put themself on the floor, on their knees. The resident was unable to give account of the incident because of confusion. The occurrence report did not have statements from Licensed Practical Nurse (LPN) and the assigned Certified Nurse's Aide (CNA) only documented they did not know what happened. The facility's investigative summary documented the resident has behavior of placing themself on the floor and will get up unassisted. The investigation documented abuse, neglect or mistreatment has been ruled out and signed by the DON and Administrator on 3/1/23. 2) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with BIMS of 10 indicating moderately impaired in cognition. The resident required total dependence of 2 persons for bed mobility, transfers, and toilet use and could not walk. Resident #3's Occurrence report dated 2/24/23 at 3:25 PM documented that the resident stated they were getting up to go to the bathroom and they slid out of the bed. LPN #1 was called by LPN #2 who observed the resident sitting on their buttocks on the bedside mat next to their bed. The report did not have a statement from LPN #2 who observed the resident on the floor. The Nurse's Progress Notes (NPN) documented that Resident#3 was found sitting on the side of the bed full of feces, resident unable to give account of incident. The facility's investigative summary completed on 2/28/23 documented the call bell was functioning but did not activate and Resident #3 was unable to give an account of the fall. The occurrence report documented different information that the resident stated they were trying to get up to go to the bathroom and slid out of bed. The NPN documented that the resident was found full of feces and the investigation documented that abuse, neglect or mistreatment was ruled out and was signed by DON and Administrator on 2/28/23. Resident#3's Occurrence Report dated 3/3/23 at 9:30 PM documented that the resident was observed on the floor next to their bed by their roommate. The occurrence report lacked documented evidence that statements were obtained from LPN #2, CNA #1 and Resident#3's roommate who had observed the resident on the floor. The facility's investigative summary completed on 3/7/23 documented Resident#3 was unable to give account due to cognitive impairment. There was no documentation of a statement from the resident's roommate or a root cause as to how the resident was found on the floor. The investigation ruled out abuse, neglect or mistreatment and was signed by DON and Administrator on 3/7/23. 3) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with 0 BIMS and staff assessment indicated resident with moderately impaired cognition. The resident required total assist with bed mobility and transfers with 2 persons assistance. The Resident Occurrence Report dated 3/3/23 documented the Resident #4 was found on a floormat next to an ultra-low bed. The report lacked documented statements from the LPN and CNA. The facility's investigative summary documented the resident had behavior of rolling off the bed on to the floormat. The investigative summary documented that abuse, neglect or mistreatment was ruled out and was signed by DON and Administrator on 3/7/23. The Resident Occurrence Report dated 3/5/23 documented Resident #4 had a low bed and was observed sliding themself out of bed onto the floor. The resident was assisted back to bed. Mattress placed on window side of the bed. The occurrence report lacked documented evidence that statements were obtained from LPN, CNA and the person who witnessed the resident sliding off the bed. The facility's investigative summary completed on 3/7/23 documented the resident has behavior of rolling off the bed into the floormat and ruled out abuse, neglect and mistreatment and was signed by DON and Administrator on 3/7/23. 4) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with BIMS of 10 indicating moderately impaired cognition. The resident required total assistance of two persons with bed mobility, transfer and toilet use. The Resident occurrence report dated 3/5/23 at 6:50 PM documented resident was found on bedside mat and resident stated they rolled out of bed. Resident denies pain, no injury noted. Resident with behavior of crawling off the bed onto floormat. The report did not have statements from the LPN and CNA. The facility's investigative report completed on 3/7/23 documented Resident has a behavior of rolling off the bed onto the floormat. The resident is extensive assistance of 2 persons for all care and Hoyer lift with transfers. The investigation ruled out abuse, neglect or mistreatment occurred and was signed by DON and Administrator on 3/7/23. The facility submitted an audit of A/Is that were conducted between 1/13/23 to 3/6/23. The audit documented there were 7 A/Is for 1/2023, 27 A/I for 2/2023 and 7 A/I for 3/2023. The DON audited all A/Is and the audit did not document any issues or concerns. Resident #2 was observed on 3/8/23 at 2:26 PM sleeping in bed. The bed is low position. Resident #3 was observed at 2:30 PM being provided care by the staff. Resident #4 was observed at 2:40 PM sleeping in bed with bed in low position, has mattress on the right side of the bed and floormat on left side of bed. Resident #5 was observed at 2:35 PM lying in low bed and floormats on the right side of bed. During an interview with the DON on 3/7/2023 at 3:45 PM stated that they started as DON on 2/20/2023. DON stated that the previous Assistant Director of Nursing (ADON) left A/I(s) that were not completed on 3/6/23. The DON stated they reviewed the A/I(s) for completion which included statements from the nurse and CNA assigned to the resident, printing of progress notes and update the care plan and they conclude the investigation. DON reviewed Resident #2's 2/26/23 occurrence and acknowledged that there was no statement from the nurse and CNA did not sign their statement. ADON concluded the investigation on 3/1/23 and DON signed off based on previous statements from the staff stating Resident #1 throws self on the floor. Resident #3's occurrence dated 2/24/23 the DON acknowledged that there was no statement from LPN #2. The occurrence dated 3/3/23, the DON acknowledged it lacked statements from LPN, CNA and the roommate who witnessed the incident. DON stated they signed off that the investigation and ruled out abuse because of Resident #3's behavior of putting self on the floormat. DON acknowledged that Resident #4's occurrence dated 3/3/23 and 3/5/23 have no statements from nurse and the CNA but concluded the incident based on resident's behavior of throwing self on the floor as stated by staff. Resident #5 occurrence dated 3/5/23 have no statements from the LPN and CNA. The DON stated they concluded and ruled out abuse and neglect on 3/7/23 because Resident #5 also has a behavior of putting self on floormats. DON stated when an incident happens the RNS is responsible for collecting statements from the staff. The facility investigation should be completed within 5 days. DON stated they were instructed by their corporate to write up the report, so they wrote and concluded some of the investigation on 3/7/23. DON also stated that they have to educate the staff on how to complete A/I report including obtaining statements from staff/residents who witnessed the incident or was present when incident occurred. During an interview with the Administrator on 3/7/2023 at 4:32 PM stated that the A/I audit was done by the DON and A/I reports were discussed during morning meeting and there were no issues identified. Administrator reviewed the six occurrence reports. The Administrator stated Resident #2's occurrence report dated 2/26/23, need more statements from staff but was concluded and abuse ruled out based on care plan and documented behaviors. Administrator stated Resident #3's occurrence dated 2/24/23 and 3/3/23 needs more statements from the LPN and CNA. The investigation is complete but could be more thorough to have the statements from the staff. Resident #4's occurrence report dated 3/3/23 and 3/5/23 needs to be completed. Administrator stated the facility have not finished the investigation but also acknowledged that the investigation was concluded and signed. Resident #5 occurrence dated 3/5/23, the Administrator stated they signed that the investigation is concluded. Administrator stated they have 5 days to complete the investigation. Administrator also stated it is hard to pick up the pieces because there is a change in management. During a reinterview with the DON on 3/8/23 at 4:24 PM they stated that a fall with major injury, unwitnessed fall, bruising, misappropriation of funds, sexual assault, neglect, sexual allegation requires a thorough investigation because it could be a potential abuse or neglect. The DON Stated they have to investigate right away because they have to report within 2 hours. The DON stated that the 6 A/I(s) that were reviewed had behaviors and does not need a thorough investigation because they did not feel there was Abuse. The DON further stated that it is not a complete investigation because not everybody signed the investigation and need statements from the staff. The DON stated the staff statements should be written within the shift the incident occurred. DON was able to conclude the investigations based on record review and notes and ruled out abuse without the staff statements. The resident has the right to fall and being that it is a behavior of the resident, DON did not think they have to run over and get statements. DON stated they audited the A/I(s) on a daily basis and A/I(s) were also reviewed in the morning meeting to determine if incident is a potential abuse that requires reporting within 2 hours. DON stated a QAPI meeting conducted on 3/8/23 discussed abuse, potential abuse and A/Is there were no issues identified. 10 NYCRR 415.4 b (3) | Plan of Correction: ApprovedMarch 23, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 610 Investigate/prevent/correct Alleged Violation I. On 1/6/2023, the facility initiated the occurrence report and investigation related to the abuse allegation on 12/10/22. Clinical record review and interviews were conducted to the assigned staff on the unit and the resident involved. The investigation summary was completed on 1/9/2023 by Administrator #1 and determined that there was no reasonable cause to believe any alleged abuse, neglect or mistreatment occurred by the involved staff. An addendum was completed on 1/13/23 by Administrator #2 with a conclusion indicating the alleged violation was unfounded. On 1/6/2023, Resident#1 was seen and assessed by the Director of Nursing and no findings of abuse ñ bruises or injuries ñ were noted. On 1/6/2023, the IDCPT reviewed residentís plan of care related to the potential to abuse/be abused and determined the resident to be a high risk for abuse due to history of a TBI and Mental and Behavior Disorder. Interventions were updated to include: ï Resident was placed on 1:1 supervision from 1/6/23 to 1/30/23, ï no male CNA or nurse assigned, ï no contact with the LPN who was the alleged perpetrator, and ï 2-person approach with care and interaction at all times As of 1/30/23, 1:1 supervision was discontinued but resident continues to be 2-person approach with care and interaction. Effective 1/12/23, resident will be addressed in the daily/24-hour report for continued monitoring by nursing, psychiatrist, and social work for issues, concerns, and any behavioral symptoms. Resident continues to receive psychological services for her [MEDICAL CONDITION] disorder and adjustment. Care plan meeting was held with the resident and family member on 1/30/23 to discuss and review the plan of care for her input. Resident and family member were in agreement with the plan of care. Resident #1 has not reported any alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, misappropriation of resident property and suspicion of a crime since 1/6/23 that needs investigation. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practices. On 1/12/23, all occurrence reports from 11/17/22 to 1/12/23 were reviewed by Administrator #2 and Director of Nursing #2 to determine if investigations were thoroughly completed and the 2-hour reporting requirement was met. No additional occurrences related to reporting of alleged violations were identified that were not reported within the 2-hour timeframe. All other residents on Unit 2 were interviewed for any concerns by Social Work. All female residents had a body assessment completed on 1/6/23 by the DNS. No issues and concerns were reported. From 1/30/23 to 2/3/23, the Social Work will conduct full house interviews of all male and female residents to identify issues and concerns related to alleged violations that require further investigation and reporting to the Administrator and appropriate authorities. All allegations identified will be thoroughly investigated according to Federal requirements and timeframes and reporting completed when indicated. The facilityís QAPI Committee and outside consultant participated in a QA meeting on 1/26/23, to discuss the deficiency findings identified at F-610 and conducted a Root Cause Analysis. During this meeting, the outside consultant provided education to the Committee members on Abuse Prevention and compliance with Federal investigation requirement and timeline that resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified. Based on the Root Cause Analysis that was part of the DP(NAME) QAPI meeting on 1/26/23, the following issues were identified that required corrective actions: ï The facilityís policy and procedure related to Abuse Prohibition and Prevention, did not address the current reporting timelines according to stated guidance in State and Federal regulations. ï The facility staff did not have the knowledge and understanding of the policy and procedure related to timeliness of report allegations of abuse, neglect, exploitation of residents, misappropriation of resident property, and reasonable suspicion of a crime, in accordance with Federal and State regulation and directives. ï Facility Administrator and DNS responsible for investigating all occurrences did not have the knowledge and understanding regarding their responsibility for completing a through investigation and meeting established reporting requirements in accordance with Federal and State regulation and directives. ï The facility did not have a system process to ensure reported allegations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source and suspicions of a crime are thoroughly investigated, preventive and protective measures initiated while the investigation is in progress, and appropriate corrective actions implemented to protect residents. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to assure continuing compliance with regulations: On 1/25/23, the outside consultant along with the Administrator and DNS conducted additional review and revised of the policies and procedures related to ìAbuse and Neglectî to address the Investigation and Reporting requirement and timelines component to ensure consistency with current Federal and State guidelines as stated in the State Operations Manual dated 10/24/22. Revisions included components of conducting a thorough investigation ñ observation, interview, and record review, preventive measures and corrective actions. Beginning 1/31/23 the outside consultant will provide education to all facility staff on Abuse Prevention policy. ï The education will include Abuse Prevention elements, the federal guidance on which occurrences are reportable and how they should be reported. ï Emphasis will be given to what constitutes abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, who is required to report, to whom allegation of violation will be reported and the reporting timeframes to the proper authorities. ï This education will continue to be provided until all facility staff receive this mandatory education. Abuse Prevention and Reporting education will be provided to all staff during orientation, on an annual and as needed basis with follow-up monitoring to ensure staff understand these protocols. On 2/1/23, outside consultant provided education and training to the Administrator, DON, ADON, and RN Supervisors on their responsibilities in conducting a thorough investigation and the timeliness of reporting of any alleged violations to the administrator and other appropriate outside agencies/authorities, according to State and Federal guidelines, including the reporting of the results of the investigation, preventative and corrective actions taken within 5 business days. Effective 2/1/23, the Director of Nursing/designee will monitor daily information shared at Morning Meeting and documented in the Daily Report and Accident/Incident Log to ensure that no allegation of abuse/crime has occurred. Immediate corrective action, such as completing an Occurrence Report and investigation, providing staff reeducation, or reporting to the state agency within the required timeframe, will be implemented as needed. IV. The facilityís compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QA Committee meeting co-chaired by the outside consultant was convened on 1/26/2023 to examine this deficiency. The facility will develop an audit tool to monitor compliance with appropriate actions taken in response to alleged violations to ensure alleged violations are thoroughly investigated, effective measures/corrective actions implemented to prevent recurrence while the investigation is in process, and results of all investigation are reported to the Administrator/designee and to the State Survey Agency within 5 working days of the occurrence. The DNS/designee will audit all Occurrence Reports and associated investigations monthly for the next 3 months. All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, including suspicion of a crime, will be included in the audit sample. All negative audit findings will be reported to the Administrator immediately and corrective actions, such as staff reeducation or enhancing investigation documentation, will be implemented as needed. The DNS will report the Occurrence Report investigation negative findings to the QAPI Committee monthly for the next three months for discussion, evaluation and follow-up corrective actions. Following this 3-month period, the DNS/designee will audit 25% of all Occurrence Reports and investigations for another 3 months. All resident allegations of any type of abuse will be included in the audit sample. All negative findings will be reported to the Administrator immediately and corrective actions implemented. The DNS will report all negative findings to the QAPI Committee monthly for this 3-month period for evaluation and discussion and to make a determination as to the ongoing need and frequency to continue this audit. Social Work will conduct resident interviews of 12 residents monthly to identify potential situations of abuse for six months and then quarterly for one year. Resident interview negative findings that may result in an alleged violation of abuse will be reported to the Administrator and DON for immediate investigation and reporting. Social Work will report negative interview findings to the QA Committee monthly for 6 months and then quarterly for one year. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. Responsibility: Director of Nursing |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: January 10, 2023
Corrected date: February 21, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY 797) the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This was evident for one (Resident #1) of 7 residents reviewed for sexual abuse. Specifically, on 12/10/2022 Resident #1 reported to their family that Licensed Practical Nurse (LPN) #1 on 12/9/2022 asked them to perform oral sex and then proceeded to touch their breast and vaginal area. The resident's family reported the incident to the Administrator on 12/10/2022. LPN #1 continued to work in the facility and had access to the resident on 12/11/2022. As of 1/6/2023 the facility did not report the allegation to the Department of Health and the law enforcement. This resulted in potential harm to Resident #1 and all other residents in the facility, that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility's policy titled Abuse revised 5/2022 documented it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. When any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed, reported or suspected by any employee ensure the resident is no longer being provided care and does not have any contact with the accused employee. The Administrator, Director of Nursing or their designee assumes responsibility for notification of the incident. The policy revealed no documented evidence 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 event that caused the allegation involve abuse or result in serious bodily injury, to the administrator and to other officials, other officials including to the State Survey Agency and Law enforcement. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS assessment tool) dated 10/19/2022 documented the resident with Brief Interview for Mental Status score of 9 indicating moderately impaired cognition. Review of the progress notes dated 12/10/2022 to 1/6/2023 revealed no documented evidence of a resident assessment or investigation related to the 12/9/2022 or 12/10/2022 sexual abuse allegation. Review of the care plans revealed no documented evidence that the resident was care planned for abuse as victim. The care plan was updated on 12/18/2022 and included risk for abuse. The care plan notes revealed no documented evidence it was updated related to 12/9/2022 or 12/10/2022 sexual abuse allegation. A review of staffing sheets dated 12/8/2022 and 12/10/2022 documented LPN #1 was scheduled during 7:00 AM-3:00 PM shift as Unit Manager for the 1st and 2nd floor. LPN #1 was not scheduled to work on 12/9/2022. During an interview with Resident #1 on 1/4/2023 at 12:38 PM they stated they were touched by a staff member identified as LPN #1. Resident #1 stated they could not recall the date, but it was dark, and it happened in their room. Resident #1 stated, LPN #1 went under my clothes and touched my breast and tried to make me suck their dick. Resident #1 further stated they told LPN #1 they were going to call the Police and LPN #1 stopped and left the room. Resident #1 stated they told their family member #1 the next day. Resident #1 was unsure of the date and time of the incident. During a telephone interview on 1/4/2023 at 2:23 PM with Resident #1's family member #1 they stated that Resident #1 reported to them on 12/10/2022 during a home visit that on 12/9/2022 LPN #1 touched their breast and vaginal area and asked them to perform oral sex. Family member #1 stated they reported the incident to the Administrator on 12/10/2022 at approximately 9-10 PM. They stated that the Administrator stated they will conduct an investigation and LPN #1 will be suspended. The family member #1 stated that the Administrator stated they will not report the incident to the Department of Health (DOH) because there was no proof. The family member #1 stated they saw LPN #1 on 12/11/2022 working in the facility The family member stated they brought Resident #1 to the Police station on 12/19/2022 to report the incident. The facility did not report the incident to the police because there was no police report. The family member stated that a care plan meeting was held on 12/29/2022 with the facility and Ombudsman #1 regarding the incident and the Administrator did not report the allegation citing there was no proof. During an interview with the Administrator on 1/4/2023 at 3:39 PM they stated that on 12/10/2022 they received a call at approximately 8:00 PM from the family of Resident #1. The family reported an allegation that an unnamed staff inappropriately touched Resident #1. The family identified the staff as LPN #1 because they wheeled Resident #1 down to the lobby to go out on pass on 12/10/2022. The Administrator stated they contacted the Director of Nursing (DON) on 12/10/2022 and informed them of the allegation. The Administrator stated they reviewed the video surveillance on their cellphone on 12/10/2022 and based on video there was no sexual contact, or any inappropriate touching or physical contact. The Administrator stated the allegation was not reported to DOH or the police because they had no finding that abuse occurred. The Administrator stated they report incidents if there is an allegation of abuse and if abuse occurred. During an interview with the DON on 1/4/2023 at 4:21 PM they stated they were not aware of any allegation of abuse involving Resident #1 and LPN #1 on 12/9/2022 or 12/10/2022. The DON stated they received a call from the administrator on 12/10/2022 and was instructed to move to Resident#1 to the 1st floor because of infection control concerns. The DON stated they first learned about the allegation during a meeting with Ombudsman #1 on 12/29/2022. The DON stated they did not do an investigation or report the allegation to the police. The DON was not aware of the facility's policy on abuse reporting and stated they have to read the policy. During an interview with the Director of SW (DSW) on 1/6/2023 at 10:08 AM they stated that the Police came to the facility on [DATE] and informed them that Resident #1's family filed a report regarding inappropriate sexual contact with a staff member. The DSW was told by the Administrator that the allegation was unfounded. During an interview with the Ombudsman #1 on 1/5/2023 at 11:33 AM they stated they were made aware of the allegation of inappropriate sexual contact between LPN #1 and Resident#1 on 12/22/2022 by the family member who called their program. The Ombudsman #1 stated they went to the facility on [DATE] and spoke with the Administrator about the allegation on 12/9/2022 and they stated that they did not report it to the DOH because the resident could not tell them what happened, and they had no proof. The Administrator stated they checked the video and did not find any proof. The Ombudsman #1 spoke to the resident on 12/22/2022 and resident reported that LPN #1, mentioning them by their name, touched them in their breast and over their vaginal area with their finger in a thrusting manner. Resident #1 did not say they were penetrated but was pointing to their vaginal area. During a subsequent interview with the DON on 1/5/2023 at 12:27 PM they stated that LPN #1 was scheduled to be off on 12/9/22 and did not come to the facility for any other reasons on that date. They stated LPN #1 last worked on 12/11/2022 on the 7-3 shift. On 12/12/2022 LPN #1 filed a leave of absence and is out sick. During a telephone interview with LPN #1 on 1/6/2023 at 11:07 AM they stated they worked on 12/11/22 on the 2nd floor. LPN #1 stated they are on leave of absence. LPN #1 stated they were not aware of any sexual allegation involving them. LPN #1 stated they have not been interviewed or asked to write a statement. LPN #1 stated they did not touch Resident #1 on their breast or vaginal area. LPN #1 stated they did not show Resident #1 their private area and did not ask Resident #1 to perform oral sex. LPN #1 was not aware of any allegation against them and was not restricted to go to the first floor. LPN #1 stated they last worked on 12/11/22 and they were off on 12/9/22. 10 NYCRR 415.4 b (2) | Plan of Correction: ApprovedFebruary 21, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F- 609 I. On 1/6/2023, Resident#1 was seen and assessed by the Director of Nursing and no findings of abuse ñ bruises or injuries ñ were noted. The IDCPT reviewed and revised the residentís care plan for the risk for abuse and updated to include the following protective interventions: ï placed on 1:1 supervision from 1/6/23 to 1/30/23 ï no male CNA or nurse assigned ï no contact with the LPN who was the alleged perpetrator ï 2-person approach with ADL care and interaction at all times. As of 1/30/23, 1:1 supervision was discontinued but resident continues to be always with 2-person approach with care and interaction. Effective 1/12/23, resident will be addressed in the daily/24-hour report for continued monitoring by nursing, psychiatrist, and social work for issues, concerns, and any behavioral symptoms. Resident continues to receive psychological services for her [MEDICAL CONDITION] disorder and adjustment. Care plan meeting was held with the resident and family member on 1/30/23 to discuss and review the plan of care for her input. Resident and family member were in agreement with the plan of care. Resident #1 has not reported any alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, misappropriation of resident property and suspicion of a crime since 1/6/23. On 1/6/2023, the facility reported the abuse allegation to law enforcement who came to the facility on the same date to investigate. The facility initiated the occurrence report related to the abuse allegation on 1/6/23 and NYS Nursing home facility incident report was completed and submitted on 1/7/23 by Corporate Nurse. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. On 1/6/2023, the Corporate Nurse provided education to all in-house staff related to the process of reporting allegations of abuse including appropriate reporting timeframes. As of 1/12/2023, all facility staff except for staffs on LOA and per diem received the required education. Staff who did not receive the education will not be scheduled to work until education is completed. On 1/12/23, all occurrence from 11/17/22 to 1/12/23 were reviewed by Administrator #2 and Director of Nursing #2 to determine if alleged violations of abuse are reported according to the 2-hour reporting requirement. No additional occurrences related to reporting of alleged violations were identified that were not reported within the 2-hour timeframe. All other residents on Unit 2 were interviewed for any concerns by the Social Work. All female residents had a body assessment completed on 1/6/23 by the DNS. No issues and concerns were reported. From 1/30/23 to 2/3/23, the Social Work will conduct full house interviews of all male and female residents to identify issues and concerns related to alleged violations that require further investigation and reporting to the Administrator and appropriate authorities. All allegations identified will be thoroughly investigated according to Federal requirements and timeframes and reporting completed when indicated. The facilityís QAPI Committee and outside consultant participated in a DP(NAME) QAPI meeting on 1/26/23, to discuss the deficiency findings identified at F-609 and conducted a Root Cause Analysis. During this meeting, the outside consultant provided education to the Committee members on Abuse Prevention and compliance with the Federal reporting requirement and timeline that resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified. Based on the Root Cause Analysis that was part of the DP(NAME) QAPI meeting on 1/26/22, the following issues were identified that required corrective actions: ï The facilityís policy and procedure related to Abuse Prohibition and Prevention did not address the current reporting guidelines and timeframes according to as stated in the current State and Federal guidance. ï Facility staff did not have sufficient knowledge of carrying out their obligations and responsibility to comply with the reporting requirement of crimes occurring in the nursing home. ï Facility Administrator and DNS responsible for investigating all occurrences did not have sufficient knowledge and understanding regarding their responsibility for meeting established reporting requirements in accordance with Federal and State regulation and directives. ï The facility did not have the system process to ensure reported allegations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source and suspicions of a crime are were reported per regulations. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to assure continuing compliance with regulations: On 1/12/23 the Administrator, DON, and Medical Director revised the Abuse and Neglect policy to include timeframe of reporting allegations of abuse to the DOH and law enforcement according to the current Federal and State guidelines. On 1/25/23, the outside consultant along with the Administrator and DNS conducted additional review and revised of the policies and procedures related to ìAbuse and Neglectî to address the Investigation and Reporting requirement and timelines component and ensure consistency with current Federal and State guidelines as stated in the State Operations Manual dated 10/24/22. Revision includes the 2-hour reporting requirement for any alleged violations of abuse, suspicion of a crime, or events that resulted to a serious bodily injury. Beginning 1/31/23 the outside consultant will provide education to all facility staff on Abuse Prevention policy. ï The education will include Abuse Prevention elements, the federal guidance on which occurrences are reportable, timeframes for reporting and how they should be reported. ï Emphasis will be given to what constitutes abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, who is required to report, to whom allegation of violation will be reported and the reporting timeframes to the proper authorities. ï This education will continue to be provided until all facility staff receive this mandatory education. Abuse Prevention and Reporting education will be provided to all staff during orientation, on an annual and as needed basis with follow-up monitoring to ensure staffs understand these protocols. On 2/1/23, outside consultant provided education and training to the Administrator, DON, ADON, and RN Supervisors on their responsibilities in conducting a thorough investigation and the timeliness of reporting of any alleged violations to the administrator and other appropriate outside agencies/authorities including the reporting of the results of the investigation, preventative and corrective actions taken within 5 business days. Effective 2/1/23, the Director of Nursing/designee will monitor daily information shared at Morning Meeting and documented in the Daily Report and Accident/Incident Log to ensure that no allegation of abuse/crime has occurred. Immediate corrective action, such as completing an Occurrence Report and investigation, providing staff reeducation, or reporting to the state agency within the required timeframe, will be implemented as needed. Effective 1/6/2023, Elder Justice Act signage about Protecting Adults from Abuse and Neglect, Patient Care NYSDOH Hotline were posted in the bulletin board of each nursing units and the ground floor indicating the facility staffsí and visitorsí reporting obligations for alleged violations and the telephone numbers for reporting complaints and ensuring a complaint investigation is completed. IV. The facilityís compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QA Committee meeting co-chaired by outside consultant was convened on 1/26/2023 to examine this deficiency. The facility will develop audit tools to monitor compliance with timely reporting of alleged violations involving abuse, neglect, exploitation, and mistreatment, including injuries of unknown origin, misappropriation of resident property, and reasonable suspicion of a crime, including the results of the investigation, to the Administrator and to the State Survey Agency, Local Law Enforcement, or other agency as per Federal regulation. The DNS/designee will audit fifteen staff members for staff knowledge and understanding of Abuse Prohibition and Reporting Protocols on a monthly basis for the next six months and then on a quarterly basis for one year. The sample will include staff from all disciplines. Corrective actions, such as reeducation, will be implemented for any negative findings. Staff Knowledge of abuse reporting protocol audit findings will be reported to the QAPI committee monthly for the next six months and then quarterly for one year for evaluation and follow-up. At the end of this period, the Committee will determine the need for ongoing monitoring specific to staff knowledge and understanding of reporting requirements and at what frequency. Social Work will conduct resident interviews of 12 residents monthly to identify potential situations of abuse for six months and then quarterly for one year. Resident interview findings that may result in an alleged violation of abuse or suspicion of a crime will be reported to the Administrator and DON for immediate investigation and reporting. Social Work will report resident interview findings to the QAPI Committee monthly for 6 months. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. The DNS/designee will audit all occurrences for alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property for the next 3 months to ensure reporting requirements are met and reported timely to the NYSDOH and/or Local law Enforcement according to regulation and State law. Corrective actions, such as reeducation or submission of a report to the State Survey Agency or Local Law Enforcement, will be immediately implemented for any negative findings. The DNS will report the occurrence audit findings to the QAPI Committee monthly for the next three months and then quarterly for one year for evaluation and follow-up corrective actions. The DNS will continue to report a summary of reported occurrences to the QAPI Committee, minimally, on a quarterly basis for discussion and additional corrective actions as indicated. Responsibility: Director of Nursing |