Massapequa Center Rehabilitation & Nursing
March 1, 2019 Complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Actual harm has occurred
Citation date: March 1, 2019
Corrected date: April 17, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (Complaint # NY 788), the facility did not ensure one (Resident #1) of three residents rights to be free from neglect. Specifically, two Certified Nursing Assistants (CNA) and a Licensed Practical Nurse (LPN) placed the resident back to bed without being assessed by a Registered Nurse (RN) after an unwitnessed fall. Thereafter, the resident exhibited a change in the transfer status that was not reported to the licensed staff. Subsequently, the resident was noted with swelling and external rotation of the right leg and was transferred to the hospital with a [DIAGNOSES REDACTED]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings were: The facility's policy titled Accident/Incident (A/I) dated 4/4/18 documented it is the policy of the facility to investigate all accidents/incidents to residents to prevent a recurrence of the same or similar type of incident. Should one witness an incident/accident or find it necessary to aid in an incident/accident victim, one should render immediate assistance. Do not remove the victim until he/she has been examined for possible injuries by an RN/MD. The facility's policy titled Fall Prevention policy 4/6/18 documented when a resident is found on the floor, the facility is obligated to investigate and try to determine how she or he had fallen and put interventions in place to prevent it from reoccurring. Fall refers to unintentionally coming to rest on the ground, or other lower level but not as a result of an overwhelming external force, an episode where a resident lost his/her balance and would fall. The facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property dated 7/20/18 defined Neglect as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All employees shall receive training annually and ongoing as necessary on Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property. The training should include definition and how to report allegations of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property without fear of reprisals. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 11/2/18 documented the resident's cognitive status as severely impaired. She required extensive assistance of one person for bed mobility, transfer, walking, locomotion and limited assistance of one for toilet use. The resident was frequently incontinent of bowel and bladder. The balance was not steady, only able to stabilize with staff assistance. The resident had a history of [REDACTED]. CNA #1 and CNA #2 received in-service on 11/8/17 and on 12/18/17 respectively for Abuse, Mistreatment and Neglect and Falls. CNA #3 received in-service (undated) for Falls. CNA #3's personnel file lacked documented evidence that she received in-service related to Activities of Daily Living (ADL) and Abuse. LPN #1 received in-service on Resident Abuse on 6/19/08 and her personnel file lacked documented evidence she had in-service recent in-service on Abuse and Falls. The resident's Fall Risk assessment dated [DATE] documented history of fall in the past 3 months, confusion, antihypertensives, psychoactive medication use and unsteady gait for the resident. The safety measures included call bell, keep resident in high visibility area when out of bed, low bed and non-skid footwear. The Comprehensive Care Plan (CCP) titled Fall/Safety dated 9/8/18, documented the resident's fall risk factors as history of falls in the last 30 days with [MEDICAL CONDITION], a decline in functional status, unsteady gait, impaired balance, and incontinence. Interventions documented to assist with ambulation and transfer as needed, utilize a preventative device such as a low bed and keep call bell within reach. The Resident Nursing Instructions (RNI- CNA plan of care) as of 9/7/18 documented the resident required limited assistance of one person with transfers. The resident was continent of bowel and bladder was scheduled to be toileted every shift and required limited assistance with toilet use. The Nursing Progress Notes (NPN) dated 11/11/18 at 3:05 PM by LPN #1 documented that during transfer the resident attempted to stand and slipped. CNA #1 and LPN #1 stopped her from falling. The RNS (#1) was notified. The resident was not injured. There was no other distress noted. The resident was placed back in the wheelchair. The progress notes lacked documented evidence that the Resident was assessed by the RN/RNS related to the incident. The Resident CNA Documentation dated 11/11/18 documented that bathing toilet use and personal hygiene were not performed during the 3PM-11PM for the resident. The 11 PM-7 AM shift, documentation included that the bed mobility, dressing, and the transfer were not performed, and the resident had no bowel movement. The NPN dated 11/12/18 at 7:46 AM by LPN #2 documented that LPN #2 observed swelling to the right upper and lower leg. The right leg was twisted. The MD was made aware and ordered an x-ray of the right upper and lower extremities to rule out a fracture. LPN #2 called and spoke to the x-ray company representative. The x-ray of right hip dated 11/12/18 at 1:44 PM documented acute comminuted [MEDICAL CONDITION] femur. The NPN dated 11/12/18 at 3:20 PM LPN #3 documented the resident had an x-ray of the right lower extremity and the results showed a [MEDICAL CONDITION]. The MD ordered to transfer the resident to the hospital. At 7:56 PM resident was transferred to the hospital for right [MEDICAL CONDITION]. The A/I report dated 11/12/18 (time not documented) documented that LPN #2 was called by the resident's companion to report the right leg swelling. Tylenol was given, and the resident slept. During morning rounds, LPN #2 observed the right leg was still swollen and twisted. The MD was made aware who ordered an x-ray. RN assessment documented the resident's right lower extremity was swollen with pain. The right lower extremity was externally rotated. The facility's investigation dated 11/12/18 documented on 11/11/18 at approximately 2 PM, LPN #1 reported to RNS #1 that during transfer from bed to chair, Resident #1 lost her balance and was sliding down, CNA #1 and LPN #1 intercepted the fall and sat her in her chair. Resident #1 then attended recreation activity. The next day (11/12/18) at about 7 AM, LPN #2 was called to the room by the resident's private companion to show that the resident's right leg was swollen. The MD was notified. An x-ray was ordered that showed a [MEDICAL CONDITION] hip. Resident #1 was transferred to the hospital for evaluation and treatment. CNA #1 and #2 both stated that they observed Resident #1 on the floor on 11/11/18. They reported it to the nurse (time not documented). After noting that there were no visible injuries and Resident #1 did not complain of pain, CNA #1, CNA #2 and LPN #1 helped Resident #1 back to bed. Then transferred her into the chair to attend a recreational activity. The facility concluded that CNA #1, CNA#2 and LPN #1 did not report an incident accurately and timely. Both CNA's and LPN would be suspended pending investigation due to delay in reporting. As of date, no evidence of abuse, neglect and/or mistreatment was identified. RNS #1 was interviewed on 1/22/19 at 1:47 PM and stated he was approached by the LPN #1 on 11/11/18 at approximately 2:15 PM. She asked him how to proceed when during transfer a resident lost her balance and staff intercepted the fall. RNS #1 asked LPN #1 more than once if the resident touched the floor. LPN #1 said no. RNS #1 told the LPN that occurrence the LPN had described was not considered an Accident or Incident (A/I). According to LPN #1, the resident did not complain of pain. RNS #1 stated if a resident did not touch the floor, it was not considered a fall unless there was a harm/injury. If the resident complained of pain after an episode of interception, there would be an assessment and investigation. RNS #1 stated he was not informed there was a fall. RNS #1 stated he did not assess the resident. The Therapeutic Recreation (TR) was interviewed on 1/22/19 at 3:08 PM and stated on 11/11/18 she was making rounds at approximately 2:00 PM when she noticed Resident #1 was on the floor in her room lying on the right side and yelling. The resident was alone in the room. The TR noticed an aide and a nurse (could not recall the staff names) in the area. She told the aide that Resident #1 was on the floor. The aide came to the room to check and she immediately found the nurse and nurse came and the TR left the area. The 7:00 AM- 11:00 PM CNA #1 was interviewed on 1/22/19 at 4:10 PM and she stated Resident #1 was on her assignment on 11/11/18 during the 7:00 AM to 3:00 PM shift. The TR (could not recall the name) said that Resident #1 was on the floor. CNA #1 called LPN #1. LPN #1 told CNA #1 to get Resident #1 up from the floor. CNA #1 called CNA #2 for help. LPN #1, CNA #1 and CNA #2 picked Resident #1 from the floor and transferred her to the bed. Then they transferred Resident #1 from bed to chair. The resident was taken to attend the activity. CNA #1 stated she was aware that she needed to wait for the RNS to complete an assessment before lifting the resident from the floor. CNA #1 stated that she followed LPN #1's instructions. Resident #1 did not complain of pain. CNA #1 also worked on 3-11 shift that day and assisted CNA #3 in transferring Resident #1 from wheelchair to bed. CNA #1 stated that she did not notify CNA #3 that the resident fell during the day shift. Resident #1 generally required the assistance of one person for the transfer but after the fall during the evening shift Resident #1 had a hard time standing, so they (CNA #1 and CNA #3) lifted her. CNA #1 stated she did not notice any swelling on the resident's leg. The 7:00 AM-3:00 PM CNA #2 was interviewed on 1/22/19 at 3:17 PM and stated on 11/11/18 she was called in the resident's room by CNA #1. Resident #1 was on the floor. CNA #1 and LPN #1 were in the room. LPN #1 asked for help in picking the resident up. The three of them picked Resident #1 from the floor and placed her in the bed. CNA #2 thought the resident was already seen by the RNS. The 7:00 AM-3:00 PM LPN #1 was interviewed on 1/22/19 at 3:24 PM and stated she worked on 11/11/19 and was assigned to Resident #1. She was informed by the TR (could not recall name and time) that Resident #1 had a fall. LPN #1 stated she paged RNS #1 and another RNS. She waited for 10-15 minutes, and no one came. LPN #1 stated CNA #1, CNA #2 and herself assisted Resident #1 up from the floor and placed her onto the bed. Resident #1 was not in pain. Resident#1 was very alert, she wanted to get up and they transferred her from bed to chair to attend an activity. LPN #1 stated she did not notice any injury to Resident #1. LPN #1 did not write an A/I report as it was the end of the shift and she did not inform the next shift about the fall. The 3:00-11:00 PM and 11:00 PM- 7:00 AM CNA #3 was interviewed on 1/22/19 at 3:55 PM and stated that she was assigned to the resident on 11/11/18 during the evening and the night shift. At approximately 7:30 PM CNA #3 went to place the resident to bed. The resident was having difficulty standing up. CNA #2 assisted with the transfer but did not mention that the resident had a fall during the previous shift. Both CNAs (CNA #2 and CNA #3) lifted the resident manually because the resident could barely stand. The resident did not complain of pain. CNA #3 stated she did not notice any swelling or rotation to the resident's right leg. During a subsequent interview with CNA #3 on 1/29/18 at 4:48 PM, she stated that Resident #1 had a private aide all night. CNA #3 checked on Resident #1 at 1:00 AM and between 5:30-6:00 AM and they were both (the resident and the companion) sleeping. CNA #3 stated she did not provide any care to the resident during the night shift because the resident was sleeping. The resident did not ring the call bell or asked for any assistance. Resident #1 slept all night and had no signs or symptoms of pain. The Director of Nursing (DON) was interviewed on 1/22/19 at 4:35 PM and stated the facility had a change in ownership and some of the in-service records for the involved staff (LPN #1 and CNA #3) could not be located. The in-service educator responsible for education in (YEAR) was no longer employed. She had perhaps discarded the records that the facility was not able to locate. The RN Risk Manager (RNRM) was interviewed on 1/22/19 at 5:11 PM, she stated she completed the investigation and concluded that the resident had a fall and was picked up from the floor by LPN #1 and CNA #1 and #2 and they did not inform anyone. There was no abuse, neglect, and mistreatment. There was a failure to follow the facility protocol of not generating an A/I and not reporting the incident. The resident was transferred to the hospital and had surgery. The involved staff were aware of the facility policy. RNS #1 should have investigated further when staff reported about intercepted fall. RNS #1 did not assess the resident. The 11:00-7:00 AM LPN #2 was interviewed on 1/25/19 at 3:29 PM and stated he worked 3-11 and 11-7 shift on 11/11/18. When he came on duty nobody reported to him that Resident #1 had a fall. Resident #1 was in a wheelchair at 3:00 PM, and she was pleasant. He did rounds at approximately 5:00-6:00 PM, 10 PM, 11 PM and in the middle of the night. Resident #1 was sleeping. LPN #2 stated the staff did not report any issues with the transfer. At approximately, 5:00-6:00 AM Resident #1 was awake and did not complain of pain. The private aide called LPN #2 between 6-6:30 AM and reported that Resident #1 did not sleep well and complained that her leg was bothering her. LPN #2 checked, the right leg was swollen and appeared twisted. Prior to this time, the CNAs did not report to him that the resident was complaining of pain or that the resident's leg was swollen or twisted. LPN #2 tried to call RNS #2 but could not reach him. LPN #2 called the MD at 7:00 AM and got an order for [REDACTED].#2 reported it to next shift LPN #3. The 7:00 AM - 3:00 PM RNS #3/Assistant Director of Nursing (ADON) was interviewed on 1/25/18 at 4:42 PM and stated on 11/12/18 he was notified of the x-ray result for the resident. RNS #3 stated Resident #1 had a swelling and external rotation of the right leg. Resident #1 was in pain and was grimacing. RNS #3 documented his assessment (no time document) in the incident report and did not document his findings in the resident's medical record. RNS #3 initiated the incident report when he saw the swelling. Resident #1 was transferred to the hospital during the 3-11 shift for further evaluation. RNS #3 stated if a nurse observes a change in condition the RNS should have been informed. The 7:00 AM-3:00 PM LPN #3 was interviewed on 1/29/19 at 1:49 PM and she stated did not get any report that Resident #1 had a fall or that Resident #1 was observed with swelling of the leg by LPN #2. LPN #3 stated she read the progress notes and read that Resident #1 had an order for [REDACTED].#1 always complained of pain. LPN #3 stated when x-ray result came (could not recall time), she called the MD. The MD ordered to transfer the resident to the hospital. The Primary Medical Doctor (PMD) was interviewed on 1/29/19 at 4:00 PM and he stated he was informed by the nurse (could not recall the name) in the morning on 11/12/18 (could not recall time) that the resident was noted with a twisted leg; he ordered an x-ray. The PMD saw Resident #1 in the afternoon. The resident was observed with a shortened right leg which was a definite sign of a fracture. Resident #1 was not in pain, but she was not comfortable. The x-ray results showed a fracture, and he ordered to transfer the resident to the hospital. PMD stated that he was not informed of a fall on 11/11/18. When he was called in the morning on 11/12/18, the nurse did not mention any fall. 415.4(b)(1)(i)

Plan of Correction: ApprovedMarch 19, 2019

F 600: Free from Abuse, Neglect and Exploitation
I. Immediate Correction:
Resident #1
1. The LPN# 1 was terminated for failure to follow facility P and P for fall investigation and RN assessment prior to moving resident.
2. CNA # 1 and CNA #2 received education and counseling on the actions to take when a resident falls.
3. CNA # 1 was suspended for failure to report the fall and the change in transfer status to 3-11 LPN #2.
4. CNA #2 was suspended for failure to report the fall.
5. The CNA # 3 received an educational counseling for not report change in transfer status to 3-11 LPN #2.
6. The LPN # 2 received an educational counseling
for failure to notify RNS regarding change in resident condition and to report this change to the oncoming LPN #3.
7. RNS # 1 received an educational counseling
For lack of follow up to investigate a reported loss of balance for Resident #1.
8. RNS#2 received an educational counseling for not documenting resident?s change in condition in medical record.

9. RNS # 3 received an educational counseling for not documenting resident?s change in condition in the medical record.
10. On 3/11/19 the Facility located the Inservice Records for CNA #3 and LPN # 1. These records faxed on 3/12/19 to the NYSDOH Central Islip office.
11. On 3/11/18 the facility contracted the services of GNYHCFA to develop and implement the directed plan of correction and directed in service education.
12. On 3/14/19 the GNYHCFA consultants convened the facility QA Committee to assess the causative factors that may have contributed to the deficiencies cited, to identify and correct causative factors, identify routine triggers to alert facility of any evolving issues and develop audit tools to monitor facility compliance with the plan of correction.

II. Identification of Others
1. The facility respectfully states that all residents could be affected by the Licensed Staff?s failure to follow facility policies for Accidents and Incident Investigation.
2. The DNS obtained a list of all residents that experienced a fall in the last 90 days and reviewed Accident and Incident form to ensure compliance with RN Assessment and investigation.
3. Any issues identified were immediately corrected.
4. 94 A/I were reviewed, All A/I reviewed had an RN assessment. 4 out of 94 A/I did not have a correlated progress note in the electronic medical record.
4. Education was provided by the Director of Nursing to the RN Supervisors on documenting assessment post fall in the medical record.
III. Systemic Changes
1. The DNS, Medical Director, Administrator in conjunction with GNYHCFA reviewed the facility Policy/Procedures for Abuse Prevention and found same to be compliant. The P/P will be re
inserviced to all staff by GNYHCFA Consultants. The lesson plan will focus on:
? Ensuring staff knowledge on abuse including neglect as failure to provide goods and services to ensure residents attain/maintain their highest level of well-being.
? Discuss the importance of communicating changes in condition.
? Review of definitions of Abuse
? Review/discuss the 7 elements of Abuse Prevention.
? Identification of reporting measures that Staff members can take when facility policies are not adhered to by other staff members.

2. The Medical Director, DNS in conjunction with GNYHCFA Consultants reviewed and revised the facility P/P for Accidents and Incident Investigation specific to Falls. This P/P will be in serviced to all Staff by the GNY Consultants The Lesson Plan will focus on
? The definition of what constitutes a fall as per CMS RAI guidelines: Unintentional change in position coming to rest on the ground, floor or next lower surface (e.g. bed,chair or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or nursing home. Falls are not a result of an overwhelming external force ( e.g. a resident pushes another resident) and an intercepted fall occurs when the resident would have fallen if he or she had not caught themselves or had not been intercepted by another person, this is still considered a fall.
? The need to communicate any incidents of resident?s sliding from wheelchair/surface or intercepted falls to the unit Charge Nurse and /or RNS.
? The Unit Nurse will report all incidents and falls to the RNS
? The responsibility of all staff to communicate to the RNS or Department Head when any resident reports that he/she fell .
? The responsibility of any staff member observing a resident falling or on the floor to announce a Mr. Trip over the intercom.
? The responsibility of the RNS to come to the unit immediately, assess the resident and document in the medical record.
? The RNS responsibility to communicate all Accident and Incidents to PMD, Resident Representative, and members of the IDT.
? All Accident and Incidents will be discussed at the morning QI meeting to identify root cause and corrective measures/interventions to be taken.

3. The Medical Director, DNS, in conjunction with GNYHCFA Consultants reviewed and revised the facility P/P specific to Residents experiencing a change in Condition. This P/P will be in serviced to all Nursing Staff by the GNY Consultants on the Lesson Plan will focus on:
? The Nursing Assistant is responsible to report to the Charge Nurse when the resident is noted with any change in condition.
? The LPN is responsible to observe the resident change and report observations of the resident, including vital signs to the RNS.
? The RNS is responsible to come to the unit, assess the resident and document in the medical record.
? The RNS responsibility to communicate all residents experiencing a change in condition to PMD, Resident Representative, and members of the IDT.
? The Unit Nurse will communication resident changes in condition to all caregivers during the Change of Shift report documenting same on 24 hour report
? The communication of all resident changes in condition to the IDT at morning QI meeting.


.
IV. Quality Assurance
1. The GNY Consultants developed an audit tool to ensure facility compliance with Abuse Prevention specific to Accident Incident reporting, response and investigation.
This audit will be done by Risk Manager for all Accident and Incident investigations weekly x 6 months and monthly thereafter. Any issues will be followed up at IDT Morning Meeting and reported to QA Committee for follow up as needed.
2. The GNY Consultants developed an audit tool to monitor compliance with facility policy for residents that experience a change in condition
This audit will be done by RNS for 4 randomly selected residents per unit from the 24 hour report weekly x 8 weeks followed by 2 residents per unit monthly x 10 months. Any issues will be followed up at IDT Morning Meeting and reported to QA Committee for follow up as needed.
3. The GNYHCFA consultants developed an audit tool to monitor the facility?s compliance with response to the Mr. Trip Code response. This drill will be conducted weekly x 2 months followed by monthly x 12 months
Any issues will be followed up at IDT Morning Meeting and reported to QA Committee for follow up as needed
V. Person Responsible for this F-Tag
1. Director of Nursing