Willow Point Rehabilitation and Nursing Center
April 7, 2017 Complaint Survey

Standard Health Citations

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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: April 7, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, observation, and interview conducted during the abbreviated survey (NY 409), it was determined that for 1 of 3 reviewed residents (Resident #1), the facility did not ensure potential violations involving mistreatment, neglect, or abuse were thoroughly investigated. Specifically, the facility did not conduct a complete and thorough investigation to ensure abuse had not occurred when a urinary catheterization procedure was completed on a resident without indication and without a physician's order. Additionally, the facility did not report the incident to the New York State Department of Health (NYSDOH) as required. Findings include: The facility's Abuse Mistreatment and Neglect policy dated 1/2017 defined abuse/mistreatment as inappropriate treatment or exploitation of a resident. Resident #1 was admitted to the facility 2/13/2017 with [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) initiated on 2/13/2017 documented the resident was alert and able to make her needs known. The CCP documented the resident was continent of bowel and bladder, and did not have urinary issues. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and able to make her needs known. She was continent of bowel and bladder. The facility investigation summary dated 2/15/2017 documented Resident #1 was alert and oriented and expressed concern that urinary catheterization (urine collection via insertion of a tube through the urethra) was not needed, prior to the procedure being performed. The summary documented LPN (licensed practical nurse) #5 completed the catheterization without identifying a corresponding physician's order, and Resident #1 was catheterized by mistake by LPN #5. The summary documented an investigation was initiated; statements were obtained; there was no evidence of abuse, neglect or mistreatment; and LPN #5 made a mistake. The summary documented LPN #5 was counseled and re-educated on 2/21/2017, six days after the incident, on providing treatments, physician orders, customer service, and communication. There was no documented evidence she was re-educated on urinary catheter procedures or care. The nursing notes dated 2/15/2017 through 2/21/2017 did not document the resident was catheterized, assessed, or monitored for any negative outcome. There was no documented evidence the physician was notified of the procedure. The 2/2017 physician orders did not document the resident was to be catheterized. The 24-hour shift-to-shift report dated 2/15-16/2017 did not document the resident was catheterized. The resident was observed on 3/20/2017 at 9:37 AM in her room, in bed eating her breakfast. She stated on the night of the incident 2/15/2017, LPN #5 entered her room and completed a bladder scan (hand-held ultrasound to assess urine volume). The resident stated both she and her husband stated there were no issues with her bladder, and the nurse continued to perform the urinary catheterization. She stated LPN #5 returned to her room later in the shift and explained to her the test was ordered for another resident and she was sorry. The resident stated no staff assessed her that night or the next day, and she had discomfort and spotting from the procedure. When interviewed on 3/20/2017 at 7:24 AM, LPN #1 stated 3 nursing Supervisors were notified of the incident on 2/15/2017 at the end of the 3 PM - 11 PM shift. He stated LPN #5 alerted them she had performed a catheterization procedure on the wrong resident. He stated the incident was discussed between the 3 of them and they were unsure how to classify this and decided it was a medication error. He stated there was a on-call person to ask for assistance, and the 3 of them decided to wait until the morning for that conversation; he did not know if the conversation took place. He stated the staff were instructed not to document on medication errors in the medical record or the 24-hour report, and the information was passed on verbally. He stated the facility policy was anything out of the ordinary was to be documented on the 24-hour report. He stated he was not sure if an assessment was completed at the time of the incident, and no assessment was completed on his 11 PM - 7 AM shift as there was no RN available. He stated this incident was an accident and was a NYSDOH reportable incident. When interviewed on 3/20/2017 at 8:03 AM, the Administrator stated he thought LPN #5 made a mistake. He stated he discussed the incident with the family the following day and he and the family agreed the incident should not have occurred. He stated the resident expressed she was embarrassed by the incident. He stated the incident was preventable and better communication was needed. He stated he did not review the investigation prior to this interview, and both he and the Director of Nursing (DON) were responsible for the completion of the investigation process. He stated the investigation time frame for completion varied, and it might take weeks for completion. He stated LPN #5 was not suspended during the investigation, as she made a mistake and was counseled and re-educated. When interviewed on 3/20/2017 at 9:58 AM, LPN #2 stated she was alerted by LPN #5 via telephone at approximately 10:30 PM on the evening of the incident, and LPN #5 explained to her she had performed a catheterization on the wrong resident. LPN #2 stated she was not qualified to complete an assessment and did not ask anyone to complete an assessment. She stated she did not talk to the resident that night, as the resident requested pain medication and wanted to go to sleep per LPN #5. She stated she talked to the registered nurse (RN) Supervisor and another LPN Supervisor at the time of the incident, and all 3 of them were unclear how to identify this incident, and decided it was a medication error. She stated her conclusion was LPN #5 made a mistake. She stated there was no documentation on the 24-hour report, as medication errors were not documented in the resident record or the 24-hour shift-to-shift report per the Assistant Director of Nursing (ADON), and the information was to be passed through verbal exchange. She stated she did not obtain any statements from the staff regarding the incident as it was the change of shift, and she did not observe Resident #1 or any other residents. She stated this was a preventable incident, was considered abuse, and was a reportable incident. She stated the DON determined reportable instances and completed the reporting process. When interviewed on 3/20/2017 at 11:40 AM, RN #3 stated at the change of shift on 2/15/2017 she was alerted LPN #5 had catheterized the wrong resident. She stated she did not conduct an assessment on Resident #1 at the time of the incident. She stated the catheterization procedure was invasive, with possible negative outcomes including irritation, inflammation, and bleeding. She stated LPN #2 was responsible to ensure the physician was contacted and to monitor the resident. She stated she was unsure if the physician was contacted. She stated the 3 Supervisors identified this incident to be a medication error and the facility policy was not to document medication errors in the resident's medical record or on the 24-hour report. She stated LPN #5 did not follow the facility policy or her basic training when performing the catheterization. She stated she would have expected documentation to be in the resident's medical record, including monitoring of the resident's condition. She stated she did not document the information on the 24-hour report. She stated there was to be a medication error report completed and she did not know who completed that. She stated she was not asked to provide any statement regarding the incident, and thought she would have been asked to provide one. She stated the incident was considered neglect and was a reportable incident. When interviewed on 3/20/2017 at 12:48 PM, LPN Unit Manager #4 stated she had met with the resident and her family the day following the incident, 2/16/2017. She stated the resident told her she questioned LPN #5 prior to the procedure being performed and asked why the procedure was being done. LPN #4 stated she was unsure how to document the incident and stated LPN #5 and the Supervisor were responsible to document in the resident's chart. She stated the resident expressed to her that she felt she been violated. She stated she did not complete an assessment of the resident or alert anyone that an assessment needed to be completed. She stated she did not recall if she had notified the physician of the incident, and did not document any information on the 24-hour report. She stated LPN #5 remained in the facility after the incident and was not monitored. She stated this incident was considered neglect and was a reportable incident. When interviewed on 3/20/2017 at 1:56 PM, the resident's assigned physician stated she did not recall being notified by the facility of the incident. She stated she would have expected an assessment to be completed at the time of the incident, as the procedure was invasive. She stated she did not complete a urinary assessment for injury. She stated she spoke to the resident and the resident was upset the catheterization was performed. The physician stated the nurse should have heeded what the resident said. When interviewed on 3/20/2017 at 3:34 PM, the DON stated LPN #5 catheterized the wrong resident. She stated the facility conducted an investigation and concluded LPN #5 made a mistake. She stated she did not obtain statements from all staff at the time of the investigation, and at that time considered the investigation to be complete. She stated the resident was not assessed by an RN, and there was no documentation of the incident in the medical record or on the 24-hour report. She stated she talked to the family and they were very upset by the incident. She stated LPN #5 was not suspended during the investigation, continued to provide care for other residents, and was re-educated on 2/21/2017. She stated she did not believe the physician was notified of the incident, and after discussion of the investigation, she did not believe the facility had conducted a complete and thorough investigation. She stated she did not define this incident as abuse or neglect, as there was no intent by LPN #5. When interviewed on 4/7/2017 at 2:48 PM, LPN #5 stated she was assigned to the unit the evening of the catheterization incident. She stated the other nurse assigned to the unit asked her if she was able to assist her with treatments, as she was behind. LPN #5 stated she went to complete the catheterization on Resident #1 without checking the treatment administration record (TAR) or clarifying the physician order. She stated when in the process of the catheterization, she realized she had performed the procedure on the wrong resident, as there was very little urine output. She stated she reported the incident to the Supervisor. She stated she did not document the procedure in the nursing notes or on the 24-hour shift-to-shift report, as she was unclear how to document the incident. 10NYCRR 415.4 (b)(2)

Plan of Correction: ApprovedJune 16, 2017

Element #1
Corrective action for Resident #1 included;
* LPN #1 apologized to the resident for the procedure being completed.
* RN assessment was completed on the morning of 2/16/17 to ensure there was no negative physical or psychological effect of the catheterization.
* Resident was allowed express her frustration.
* The resident's attending physician completed an examination and history and physical on 2/16/17. She did not identify any negative effects from the catheterization.
* Director of Nurses and Clinical Care Coordinator met with Resident #1's family to review investigation, root cause for the incident and extended reassurance that the matter was being addressed.
* The facility staff initially determined that this error, because there was no injury or harm to the resident, did not rise to the level of required reporting to DOH per resident abuse regulations.
* Resident met her rehab goals successfully and was discharge home on 4/15/17.
The facility was notified of the DOH investigation by the Attorney General and later the Department of Health surveyor. The facility assisted with their investigation of this incident.
Thorough investigation of this incident was completed retrospectively and the root cause was identified. Review of action taken re: investigation process by LPN, RN, Shift Supervisor, DON and Administration was completed.

Element #2
Other residents having the potential to be affected by the same deficient practice will be identified by:
* Nurses include clinical procedures on the 24 hour report for ongoing monitoring and needed investigation.
* All Medication/Treatment Incident Written Reports will be documented, and reviewed by shift supervisor, Clinical Care Coordinator and Assistant Director of Nurses to ensure complete investigation including consideration of abuse reporting requirements.
* Director of Nurses and Administrator are notified of any violation of Medication/Treatment order.
* All 24 hour reports will be reviewed daily to identify any potential concerns that warrant further investigation and reporting to DOH for abuse, neglect, mistreatment or exploitation and potential suspension of staff.
* Administrator, Director of Nurses or Nursing Supervisor will determine if the nurse involved needs to be removed from resident care and the incident reported to the New York State Department of Health.
* All licensed nursing personnel will be re-educated regarding the updated abuse investigation,reporting policy, including suspension of staff, and the Medication/Treatment Incident Written Report Policy and form.
Element #3
The measures that were put into place to ensure deficient practice does not recur include:
* The abuse reporting and investigation policy was reviewed and found to be accurate.
* The Medication/Treatment Incident Written Report policy and form were reviewed and updated to include the reporting of a treatment error. Revisions include;
- reporting errors to shift supervisor for review and determination of potential abuse, neglect, mistreatment or exploitation.
- Completed report is forwarded to the Clinical Care Coordinator, then to Nursing Administration for necessary follow up.
* The Guidelines for Accident/Incident Reporting were reviewed and updated to include notifying the administrator or the administrator on-call for medication/treatment errors at the time the error is discovered.
* Re-educated nurses regarding the requirement to determine, per abuse investigation regulations, whether the nurse involve needs to be removed from resident care and the incident reported to the New York State Department of Health.
* All licensed nursing personnel were re-educated on the abuse reporting and investigation policy and the revised Medication/Treatment Incident Written Report policy and form by 5/26/2017.
Element #4
The corrective action will be monitored to ensure deficient practice does not recur by the following:
* Audit 100% of all Medication/Treatment Incident Written Reports to ensure established procedures for investigation for ruling out or reporting of abuse, neglect, mistreatment or exploitation are followed. Specifically, documentation on the EMR, 24 hour report, determination of needed suspensions of staff and notification of DON and Administrator will be audited. Audits will be weekly for 3 months.
* Report results to monthly QAPI committee to determine if additional audits/monitoring is warranted.
* The facility threshold will be 100%. The Associate Director of Nursing and the Director of Nursing will be responsible for this plan of correction.





FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 7, 2017
Corrected date: June 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the abbreviated survey (NY 409), it was determined for 1 of 3 residents reviewed for quality of care (Resident #1), the facility did not ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, for Resident #1 who was catheterized by facility staff without a physician's order, the facility did not ensure the resident was assessed by a qualified professional, and the facility did not ensure the resident's concerns were addressed and monitored. Findings include: The facility's urinary catheterization policy updated 4/2015 documented intermittent catheterization was to be completed when there was an order by the attending physician, and the procedure was to be explained to the resident. Resident #1 was admitted to the facility 2/13/2017 with [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) initiated on 2/13/2017 documented the resident was alert and able to make her needs known. The CCP documented the resident was continent of bowel and bladder, and did not have urinary issues. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and able to make her needs known. She was continent of bowel and bladder. The facility investigation summary dated 2/15/2017 documented Resident #1 was alert and oriented and expressed concern that urinary catheterization (urine collection via insertion of a tube through the urethra) was not needed, prior to the procedure being performed. The summary documented LPN (licensed practical nurse) #5 completed the catheterization without identifying a corresponding physician's order, and Resident #1 was catheterized by mistake by LPN #5. The 2/2017 physician orders did not document the resident was to be catheterized. The nursing notes dated 2/15/2017 through 2/21/2017 did not document the resident was catheterized, assessed, or monitored for any negative outcome. There was no documented evidence the physician was notified of the procedure. The 24-hour shift-to-shift report dated 2/15-16/2017 did not document the resident was catheterized. The resident was observed on 3/20/2017 at 9:37 AM in her room, in bed eating her breakfast. She stated on the night of the incident 2/15/2017, LPN #5 entered her room and completed a bladder scan (hand-held ultrasound to assess urine volume). The resident stated both she and her husband stated there were no issues with her bladder, and the nurse continued to perform the urinary catheterization. She stated LPN #5 returned to her room later in the shift and explained to her the test was ordered for another resident and she was sorry. The resident stated no staff assessed her that night or the next day, and she had discomfort and spotting from the procedure. When interviewed on 3/20/2017 at 7:24 AM, LPN #1 stated 3 nursing Supervisors were notified of the incident on 2/15/2017 at the end of the 3 PM - 11 PM shift. He stated LPN #5 alerted them she had performed a catheterization procedure on the wrong resident. He stated the incident was discussed between the 3 of them and they decided to wait until the morning to decide what type of incident it was; he did not know if the conversation took place. He stated he was not sure if an assessment was completed at the time of the incident, and no assessment was completed on his 11 PM - 7 AM shift, as there was no RN available. When interviewed on 3/20/2017 at 8:03 AM, the Administrator stated he thought LPN #5 made a mistake. He stated he discussed the incident with the family the following day and he and the family agreed the incident should not have occurred. He stated the resident expressed she was embarrassed by the incident. He stated the incident was preventable and better communication was needed. When interviewed on 3/20/2017 at 9:58 AM, LPN #2 stated she was alerted by LPN #5 via telephone at approximately 10:30 PM on the evening of the incident, and LPN #5 explained to her she had performed a catheterization on the wrong resident. LPN #2 stated she was not qualified to complete an assessment and did not ask anyone to complete an assessment. She stated she talked to the registered nurse (RN) Supervisor and another LPN Supervisor at the time of the incident. LPN #2 stated she did not talk to the resident that night, as the resident requested pain medication and wanted to go to sleep per LPN #5. When interviewed on 3/20/2017 at 11:40 AM, RN #3 stated at the change of shift on 2/15/2017 she was alerted LPN #5 had catheterized the wrong resident. She stated she did not conduct an assessment on Resident #1 at the time of the incident. She stated the catheterization procedure was invasive, with possible negative outcomes including irritation, inflammation, and bleeding. She stated LPN #2 was responsible to ensure the physician was contacted and to monitor the resident. She stated she was unsure if the physician was contacted. She stated the 3 Supervisors were aware of the incident. She stated LPN #5 did not follow the facility policy or her basic training when performing the catheterization. She stated she would have expected documentation to be in the resident's medical record, including monitoring of the resident's condition. She stated she did not document the information on the 24-hour report. When interviewed on 3/20/2017 at 12:48 PM, LPN Unit Manager #4 stated she had met with the resident and her family the day following the incident, 2/16/2017. She stated the resident told her she questioned LPN #5 prior to the procedure being performed, and asked why the procedure was being done. She stated the resident expressed to her that she felt she been violated. She stated she did not complete an assessment of the resident or alert anyone that an assessment needed to be completed. She stated she did not recall if she had notified the physician of the incident, and did not document any information on the 24-hour report. When interviewed on 3/20/2017 at 1:56 PM, the resident's assigned physician stated she did not recall being notified by the facility of the incident. She stated she would have expected an assessment to be completed at the time of the incident, as the procedure was invasive. She stated she did not complete a urinary assessment for injury. She stated she spoke to the resident and the resident was upset the catheterization was performed. The physician stated the nurse should have heeded what the resident said. When interviewed on 3/20/2017 at 2:11 PM, the Director of Nursing (DON) stated LPN #5 catheterized the wrong resident. She stated the facility conducted an investigation and concluded LPN #5 made a mistake. She stated the resident was not assessed by an RN, and there was no documentation of the incident in the medical record or on the 24-hour report. The DON stated she talked to the family and they were very upset by the incident. She stated she did not believe the physician was notified of the incident. When interviewed on 4/7/2017 at 2:48 PM, LPN #5 stated she was assigned to the unit the evening of the catheterization incident. She stated the other nurse assigned to the unit asked her if she was able to assist her with treatments, as she was behind. LPN #5 stated she went to complete the catheterization on Resident #1 without checking the treatment administration record (TAR) or clarifying the physician order. She stated when in the process of the catheterization, she realized she had performed the procedure on the wrong resident, as there was very little urine output. She stated she reported the incident to the Supervisor. She stated she did not document the procedure in the nursing notes or on the 24-hour shift-to-shift report, as she was unclear how to document the incident. 10NYCRR 415.12

Plan of Correction: ApprovedJune 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1
The corrective action taken for Resident #1 includes:
* LPN #1 apologized to the resident for the procedure being completed.
* RN assessment was completed on the morning of 2/16/17 to ensure there was no negative physical or psychological effect of the catheterization.
* Resident was allowed express her frustration.
* The resident's attending physician completed an examination and history and physical on 2/16/17. She did not identify any negative effects from the catheterization.
* DON and CCC met with Resident #1's family to review investigation, root cause for the incident and extended reassurance that the matter was being addressed.
* Investigation of resident's statement to the surveyor re: spotting was completed. Resident was 1 assist with supervision for toileting during that period of time. Staff were interviewed and stated no spotting was observed and she did not verbalize any discomfort.
* Resident #1 met her rehab goals successfully and was discharge home on 4/15/17.
LPN #1 received written counseling regarding this incident.
LPN #1 was re-educated re: proper identification of resident with catheterization procedures, confirming physician orders [REDACTED].

Element #2
Other residents having the potential to be affected by the same deficient practice will be identified by:
All residents who had an order for [REDACTED].

Element #3
Measures that were put into place to ensure deficient practice does not recur include:
* The Intermittent Bladder Catheterization policy was reviewed and confirmed that proper identification of resident and confirming physician order [REDACTED].
* The Medication/Treatment Incident Written Report policy and form were reviewed and revised to include the reporting of a treatment error. Revisions include:
- RN assessment for each medication and treatment
error at the time the error is discovered,
- monitoring the resident every shift for 72 hours for
any adverse effects or resident concerns.
The existing policy includes notification of attending physician of incidents and their response.
* The RN Supervisor on duty at the time of the error was counseled regarding the need to complete timely clinical assessments in the event of a treatment error.
* All licensed nurses were re-educated regarding the revised policy.
* The shift supervisor is responsible to review and sign each Medication/Treatment Incident Written Report on the shift that it occurs.
* Completed report is forwarded to the Clinical Care Coordinator, then to Nursing Administration for necessary follow up.

Element #4
The corrective action to monitor and ensure deficient practice will not recur include:
Nursing administration will conduct audits of all Medication/Treatment Incident Written reports weekly for 3 months. Audit will include:
*Completion of RN assessment
*Documentation of 72 hours of documentation in nurses notes.
*Documentation on 24 hour report.
*Physician/NP notification occurred.
*Resident concerns if any, were addressed as related to the report.
The QAPI committee will review the audit outcomes each month to determine if more audits are warranted. The facility threshold will be 100%. The Associate Director of Nursing and the Director of Nursing will be responsible for this plan of correction.