Loretto Health and Rehabilitation Center
December 15, 2017 Complaint Survey

Standard Health Citations

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: December 15, 2017
Corrected date: February 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during an abbreviated survey (NY 590) it was determined for 1 of 3 residents (Resident #2) reviewed for abuse, the facility did not ensure all allegations involving abuse, neglect or mistreatment were thoroughly investigated. Specifically, the investigations into resident to resident altercations involving Resident #2 were not thorough and complete to ensure interventions to prevent reoccurrence remained appropriate and effective. Findings include: Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 7/25/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and he required supervision with transfers and ambulation. The MDS also documented the resident utilized a wheelchair and had no lower extremity impairment. The comprehensive care plan (CCP) dated 3/21/2017 documented the resident had a history of [REDACTED]. Interventions included to monitor his behaviors around other female residents and 15 minute checks. The investigative summary form dated 4/9/2017 at 10:30 AM, documented a certified nurse aide (CNA) witnessed the resident touching a female resident's arm and breast. This occurred in the lobby of the unit and he was immediately instructed to move away from the other resident. The report documented the resident's care plan was followed. The plan to prevent reoccurrence was to place the resident on 15 minute checks and monitor him while out in common areas. The only statement attached with the investigation was from the witnessing CNA. The report did not identify the residents current plan included 15 minute checks or why the 15 minutes checks had not prevented the incident as planned. The 15 minute check sheet documented the CNAs were identifying the resident's location every 15 minutes prior to and up to the 4/9/2017 incident. The 15 minute check sheet on 4/9/2017 documented the resident was in his room at 9:15 AM until 12:30 PM. The incident occured at 10:15 AM in the lobby. There was no documentation the discrepency in the location identified on the 15 minute check sheet and incident location was investigated. A physician order [REDACTED]. The 15 minute checks were documented from 4/1/2017 and continued up to 8/14/2017 when another resident to resident altercation occurred. The 8/14/2017 12:15 AM investigation documented a CNA witnessed the resident touching another female resident on her inner thigh in the unit lounge. The investigation documented the plan to prevent reoccurrence was to place the resident on 15 minute checks and ensure he was monitored while out in common areas. The report did not identify the residents current plan already included 15 minute checks or why the 15 minutes checks had not prevented the incident as planned. The 15 minute checks documented on 8/14/2017 the resident was in his room from 11:30 PM on 8/13/2017 until 6:30 AM on 8/14/2017. The incident occured on 8/14/2017 at 12:15 AM in the unit lounge. There was no documented evidence the 15 minute check documentation was reviewed for the incident on 8/14/2017 at 12:15 AM to ensure the resident's care plan was followed and the current interventions to prevent reoccurrence remained appropriate. During an interview with CNA #1 on 11/ at 11:45 AM he stated the resident sat outside the dining room for meals as he liked to touch the female residents and they had to keep a really close eye on him. He stated the resident self-propelled his wheelchair and they have to watch where he goes on the unit as he would just reach over and touch them. During an interview with CNA #6 on 11/8/2017 at 10:40 AM he stated the resident self-propelled his wheelchair around the unit and usually just went from his room to meals and then back to room. He stated the resident was on 15 minute checks which meant he had to visualize the resident every 15 minutes and if he was seen near another female resident he would watch him to ensure he did not touch her. He was not aware of any recent incidents of him touching another resident and did not think there had been an incident in over a year. During an interview with RN #7 on 11/8/2017 at 11:22 AM she stated she was the nursing supervisor during the incident with the resident on 4/9/2017 and she had obtained statements from the staff including the resident. She reported the incident to the Director of Nursing who instructed her to place the resident on 15 minute checks. RN #7 stated she did not believe the resident was on 15 minute checks at the time of incident. During an interview with RN #8 Unit Manager on 11/8/2017 at 11:35 she stated the resident had a history of [REDACTED]. When an incident occurred, she would review the incident report to ensure the resident's care plan had been followed. She did not think the resident was on 15 minute checks when the incidents in (MONTH) and (MONTH) happened as those were the preventative measures initiated to prevent reoccurrence. She reviewed the incident reports and stated she would not have gotten a statement from the resident's CNA as the important statement would be from the witness. RN #8 stated she did not recall reviewing the 15-minute documentation while investigation the incidents. During an interview with the DON on 11/8/2017 at 11:50 AM she stated she reviewed every incident report and if she had questions or needed clarification she would return the report to the Unit Manager to follow up. Preventative measures for the resident included 15 minute checks in which staff are to visualize the resident every 15 minutes and thought that intervention remained effective as it allowed staff to observe him frequently. She stated she did not review the 15-minute documentation during the 2 incidents. She stated she did not speak with the resident's assigned CNA. She stated she should have spoken to the assigned CNA as the 15 minute checks had been part of residents' care plan at the time of the incidents. During an interview on 12/15/2017 at 10:50 AM with CNA #10 , she stated the resident had a history of [REDACTED]. The resident was on 15 minute checks during the incident in (MONTH) and she could not recall any specific details regarding the incident as she did not see. She stated if she signed the 15 minute checks she would have been assigned to care for that resident and when on 15 minute checks you were to check on the resident's location every 15 minutes. She could not recall giving a statement for the incident on 8/14/2017 or asked about his location at the time as she did not see it happen. 10 NYCRR 483.12 (c)

Plan of Correction: ApprovedJanuary 11, 2018

?Resident #2 was seen by psych services and by the NP and a medication
adjustment was made.
Reviewed any patients in house that are on 15 minutes checks to ensure that this plan is appropriate and has been effective.
An ?Every 15 Minute check Policy? has been developed and education was initiated and will be ongoing to all staff.
Policy includes:
?Documentation of every 15 minute checks to include location of resident.
?LPN charge nurse to ensure documentation completed each shift.
?Nurse Manager or designee to review the every 15 minute check record a
minimum of weekly.
?The IDCP team will reevaluate, on a weekly basis, the continued need for
every 15 minute checks or the discontinuation of the checks.
?Nurse Manager or designee will be responsible for documenting, in the EMR
and on the care plans, after the IDCP team review of the data, that either
supports the continuation or discontinuing of the every 15 minute checks
and the rationale.
An audit has been developed to monitor compliance to the policy. The audit will be completed weekly on all residents that are on every 15 minute checks by the ADON and reviewed by the DON.
This audit will be completed for a minimum of three (3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings to assure compliance is met and reoccurrence is prevented. The Quality Assurance Committee will provide input on the need to continue, discontinue, or modify the audits after the three (3) month period.
The date for correction is (MONTH) 12, (YEAR). The Director of Nursing is responsible to ensure continued compliance.
?Encouraged resident to participate in activities in lounge and in room.
?Resident sits outside the dining room at a table for meals per resident
choice with staff monitoring to ensure female residents stay at a safe
distance from resident #2.
?Resident prefers to keep to himself and only come out of his room for
meals. Likes to watch TV in his room alone and not in a group setting.
?Psychological consult and social work involvement.
?Staff encourage appropriate behaviors towards other residents.
?Staff offered other activities such as books, magazines that interest
resident such as hunting magazines.
?Staff continue to try to engage resident in conversations that are of
interest to him.
?Spiritual care has visited resident but he has declined the support and
engagement.
Resident #2 was placed on ISM to monitor interactions with others. Resident #2 will be followed routinely by psych services.
Reeducation of all management and supervisors to ensure that all staff statements/interviews are obtained and to review care plan to ensure change in interventions.
Weekly audit by ADON?s on residents that are on every 15 minute checks to monitor compliance to the policy. The audit will be completed weekly on all residents that are on every 15 minute checks by the ADON and reviewed by the DON.
Yes, Nurse Managers educated with expectations of all staff statements /interviews are to be obtained. ADONs are monitoring all applicable statements are present upon review.
Weekly audit by ADON?s to ensure that all staff statements/interviews are obtained and to ensure alternate changes in the plan of care are in place.
Repeat Interventions and Q 15 min. Check Audit
DATE:_______________ Auditor:____________
Directions: Weekly care plan, EMR and every 15 minute log sheet audit, Accident/Incident Investigations, staff assignment sheet

Care Plan YES NO
Prior interventions trialed documented in Care Plan?
Are they dated when initiated?
Are there specific goals?
Are there outcomes and rationale for changes?
EMR
Documentation in EMR that the IDCP team reviewed
the data and either supports the continuation or
discontinuing of the every 15 minute checks and
the rationale?

Every 15 minute log sheets
Is all data on the log sheets?
Signatures, location of resident).
Is there a signature from either the Nurse
Manager/designee, weekly that the forms were reviewed?

Revised Care Plan included with investigation?
Change in intervention?
Copy of staff assignment sheet included with investigation?
All staff interviewed?