Auburn Rehabilitation & Nursing Center
April 14, 2023 Complaint Survey

Standard Health Citations

FF12 483.7:ADMINISTRATION

REGULATION: § 483. 70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 14, 2023
Corrected date: N/A

Citation Details

None

Plan of Correction: ApprovedMay 14, 2023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Directed QA meeting held 5/4/23 Facility Administration received allegations against licensed practical nurse (LPN) #1 who was drowsy/sleeping while on duty. There was no documented evidence the facility immediately removed LPN #1 from having access to residents while investigations were pending, no documented evidence thorough investigations were completed to rule out neglect, and no documentation allegations were addressed immediately when received by Administration. Facility staff did not immediately report all concerns of possible resident neglect immediately to facility Administration. There was no documented evidence investigations were completed to ensure no misappropriation of resident narcotics occurred when LPN #1 was relieved of their medication administration duties when unable to perform those duties by facility staff. The facility did not report allegations of neglect to the New York State Department of Health (NYS DOH) until a completed investigation could be completed and neglect ruled out Facility Administration did not immediately remove LPN #1 from having access to residents while thorough investigations were ongoing and in process completed. Facility did not ensure the corrective action plan they developed to assist LPN #1 with performance issues example (limiting work hours) was implemented and carried out correctly. The administration did not complete a thorough investigation into narcotics reconciliation after being notified the nursing Supervisor removed LPN #1 from having access to medications after they suspected LPN #1 was under the influence??®??Ç Facility staff did not adhere to the social Networking/Cell phone policy while working. A video was posted to Facebook of LPN #1 not being able to perform her job duties??®??Ç Facility staff did not follow proper procedure for reporting staff concerns related to potential working conditions under suspected under the influence of drugs and or alcohol??®??Ç Facility did not have a policy/procedure for facility staff to guide them when other staff where suspected to be under the influence of alcohol/drugs 100% audit of all resident's individual narcotic sheets for dates 3/3/23-3/26/23 completed, all scheduled, and prn narcotics were appropriately accounted for on narcotic sheets 100% audit of all resident's grievances from 3/26/23-2/26/23 no identified care issues related to LPN #1 Partnership with the Statewide Peer Assistance for Nurses was initiated for facility staff to assist and foster a collaborative relationship with reporting/recognizing staff substance abuse The DNS, ADNS, and Administrator have been re-educated on CMS guidance F600 by the Corporate Administrator and QA consultant RN. The following measures and/or systemic changes have been developed/implemented in order to ensure that the deficient practice will not reoccur: Facility policy on Social Networking has been reviewed and appropriate 100% of facility staff educated on the facility Social Networking policy Facility policy on Cell Phone has been reviewed and appropriate 100% of facility staff educated on the facility Cell Phone policy Facility policy on Emergency Notification of Management instituted. 100% of facility staff educated on the facility Emergency Notification of Management policy 100% of facility staff educated on the facility timely notification of Abuse /Neglect/Mistreatment Facility Corporate Compliance policy was reviewed and no changes 100% of facility staff educated on Corporate Compliance including the confidential phone number for staff, residents, visitors to report concerns Partnership with the Statewide Peer Assistance for Nurses ongoing Facility instituted a new policy on Purposeful rounding; specifically, regarding staff changes in condition Licensed Nursing staff to be educated Purposeful rounding; specifically, regarding staff changes in condition 100% of facility staff educated on specific sections of the employee handbook covering Code of Conduct, the problem-solving procedure, Code of Ethics, Drug and Alcohol 100% of facility staff educated on employee handbook covering Code of Conduct, the problem-solving procedure, Code of Ethics, Drug and Alcohol Facility instituted a new policy Suspicion of Drug/[MEDICAL CONDITION] and testing.??ÿ Licensed Nursing staff to be educated on the new policy Suspicion of Drug/[MEDICAL CONDITION] and testing specifically once a concern/complaint is made to administration /management the staff member is removed from duty immediately pending a thorough investigation. Facility Policy on Controlled Substance; Access to Narcotic storage and locked drug areas reviewed and revised specifically to include- Narcotic sheets shall be stored in a binder and medical records will collect monthly to ensure secure storage Licensed staff educated on Controlled Substance; Access to Narcotic storage Facility policy on Controlled Substance; Access to Narcotic storage outlines a process for investigating narcotic count discrepancies, policy remains appropriate. Licensed Nursing staff will be re-educated on investigating narcotic count discrepancies per Controlled Substance; Access to Narcotic storage Medical Records to be educated on the new process of ensuring proper storage of narcotic sheets Education provided by Consultant RN 5/5/23 2130,2315, 5/6/23 1430,2315,5/7/23,1415,2130, 2345, 5/8/23 1315 Targeted staff all department heads, all licensed nursing staff The DNS, ADNS, and Administrator have been re-educated on CMS guidance F600 by the Corporate Administrator and QA consultant RN. The DNS, ADNS, and Administrator have been educated on the Discipline -Corrective Action policy; specifically, as it relates to removing staff from work pending allegations immediately protecting residents. The DNS has been educated on her job description, review of policy and procedures specifically Social Networking, Cell Phone, Emergency Notification of Management, Abuse-Investigating and reporting, Corporate Compliance, Controlled Substance; Access to Narcotic storage and investigating narcotic discrepancies, Suspicion of Drug/[MEDICAL CONDITION] and testing, on Purposeful rounding; specifically, regarding staff changes in condition, employee handbook covering Code of Conduct, the problem-solving procedure, Code of Ethics, Drug and Alcohol . 4) The following monitoring activities will be/have been implemented in order to ensure that the deficient practice will not reoccur: QA consultant will review daily with Administration for four weeks all staff suspicion/concerns that is a violation of staff behavior related to the employee handbook ??®??Ç Follow-up by QA Committee for data analysis & identified issues ??®??Ç Revision of facility policies & procedures as needed Responsible Party: Director of Nursing

FF12 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 14, 2023
Corrected date: N/A

Citation Details

Based on observation, record review, and interview during the abbreviated survey (NY 544), the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 37 of 89 residents (Residents #1-37). Specifically, facility Administration, including nursing management, was notified when licensed practical nurse (LPN) #1 was unable to perform their job duties and failed to: - immediately remove LPN #1 from having access to residents while thorough investigations were completed. - ensure the corrective action plan they developed to assist LPN #1 with performance issues (limiting work hours) was implemented. - complete a thorough investigation into narcotics reconciliation after being notified the nursing Supervisor removed LPN #1 from having access to medications after they suspected LPN #1 was under the influence. Findings include: Refer to F600 - Free From Abuse and Neglect During a telephone interview with registered nurse Supervisor (RNS) #16 on 4/12/23 at 11:03 AM, they stated on a night in early (MONTH) 2023 (later noted to be the night shift of 3/3/23 into 3/4/23), they removed LPN #1 from the medication cart because they suspected LPN #1 was under the influence as they were nodding off. They called the Assistant Director of Nursing (ADON) and asked them to come to the facility to observe LPN #1's condition. LPN #1 left the facility before the ADON arrived and staff called 911 because they did not think LPN #1 was safe to drive. RNS #16 stated they spoke to the ADON the following day and reiterated their concerns that LPN #1 was under the influence while working. During a telephone interview with LPN #5 on 4/5/23 at 8:59 AM, they stated they worked from 11:00 PM on 3/3/23 to 7:00 AM on 3/4/23 and LPN #1 was relieved of their duties by RNS #16 as LPN #1 was incoherent. LPN #5 notified the ADON and stated they thought LPN #1 was under the influence. LPN #5 stated they notified the Administrator and Director of Nursing (DON) of their concerns and told them they sent LPN #1 home and notified the police due to a suspicion LPN #1 was under the influence. The DON replied to take LPN #1 off the schedule for the weekend until the DON could talk to LPN # 1. A text message from LPN #5 to the DON and Administrator dated 3/4/23 at 12:58 AM documented: - (LPN #1) was under the influence, RNS #16 took the (medication) cart from LPN #1 and told them to rest to keep them at the facility. The ADON was notified of the event and was to come in, and LPN #5 called and left a voicemail for the ADON to let them know LPN #1 left. LPN #5 tried to keep LPN #1 there, but LPN #1 went out the back door. Police were notified by LPN #5 as they were concerned LPN #1 was unsafe to drive. - The DON's text message reply documented ok, is (LPN #1) on the schedule for this weekend? LPN #5 replied yes. A statement completed by the DON on 3/29/23 documented on 3/3/23, LPN #5 called the DON and the Administrator around 1:00 AM to notify them LPN #1 was drowsy and falling asleep and the LPN was relieved of their medication cart and was resting in the front office. LPN #5 offered to call 911 and LPN #1 declined. The DON took LPN #1 off the schedule for the weekend and spoke to LPN #1 the following Monday. LPN #1 reported they took migraine medication which caused them to be drowsy. The LPN appeared without any impairments and was placed back on the schedule. Disciplinary Action Reports documented: - on 3/6/2023, LPN #1 was late on 6 occasions and was counseled on being on time for shifts and shift report. - On 3/21/2023, LPN #1 was counseled for staying on the overnight shift when fatigued and they were advised not to work past the 3:00 PM-11:00 PM shift to ensure the employee was on time and well rested. - On 3/24/2023, LPN #1 was late for their shift on 11 occasions and was spoken to regarding routine habits, if trouble with sleep patterns, and suggested strategies to combat fatigue. There was no documented evidence any of the above reports were reviewed with LPN #1 when they were prepared. All were signed by LPN #1 on 3/30/2023 and none were signed by the person completing the discipline, a witness, Manager, or Administration. The reports were noted as prepared by the Human Resources (HR) Coordinator. A timeline of LPN #1's employment signed and dated by the DON on 3/29/2023 documented: - LPN #1 started working on 2/16/2023 and worked 28 shifts; 13 were 12 hour shifts or double shifts and LPN #1 worked 8 days in a row leading up to 3/26/ 2023. - On 3/3/2023, LPN #1 worked overnights. At 1:00 AM, the DON and Administrator received a call from LPN #5 that LPN #1 was falling asleep, relieved of medication cart duties, and was asleep in the front office. Facility staff offered to call 911 and LPN #1 declined. - On Monday 3/6/2023, LPN #1 came in and spoke with Administration and reported taking migraine medication that caused drowsiness. LPN #1 was placed back on the schedule. - On 3/16/2023, it was reported that LPN #1 was drowsy on the overnight shift on 3/15/2023 and agreed they would not work double shifts. - On 3/20/223, LPN #1 was found sleeping in their car after their shift by LPN Unit Manager #13 who knocked on the car window and woke them up. - On 3/24/2023, spoke with LPN #1 about the upcoming weekend and need to be on time. The plan going forward due to reported personal issues and lack of sleep was they would only work scheduled shift and would not stay for additional shifts. LPN #1's Timesheet documented they continued to work double shifts/night shifts following the identified concern and the documented plan they would not work doubles or extra shifts: - on 3/17/23 from 5:19 PM to 3:10 AM on 3/18/23; - on 3/19/23 from 11:49 PM to 7:22 AM on 3/20/23; - on 3/20/23 from 5:30 PM to 8:21 AM on 3/21/23; - on 3/23/23 from 3:25 PM to 12:15 AM on 3/24/23; - on 3/24/23 from 4:25 PM to 1:00 AM on 3/25/23; and - on 3/26/23 from 4:00 PM to 12:45 AM on 3/27/ 23. On 3/28/2023, complaints from a staff member and multiple third parties were reported to the New York State Department of Health (NYS DOH) alleging LPN #1 was sleeping while administering medications. The complaint included a video that was posted to social media. The video was viewed, and the following was observed: a 33 second video of a staff member (later identified as LPN #1) standing at a medication cart. A drawer to the medication cart was open and the staff member was having difficulty standing up, leaning over the medication cart, and had their eyes closed at times. The facility's 3/27/23 and 3/28/23 investigation included staff statements from CNAs #2, 3, and 4 stating LPN #1 was observed to be sleeping at the medication cart on the evening of 3/26/ 23. The Change of Shift Controlled Medication Count sheet did not contain any documented entries for 3/26/ 23. None of the nurses who worked signed as counting narcotics with the oncoming shift that date. There was no documented evidence of a medication review or narcotic review for the residents on LPN #1's assignment on 3/26/ 23. In an interview on 4/3/23 at 1:49 PM, LPN #6 stated: - LPN #1 always looked tired, like they were going to pass out, slurred their speech, swayed at times, was always leaning on the medication cart, often seemed disoriented, and was typically absent most of the shift, up to 5 to 6 hours out of an 8-hour shift. - LPN #6 did not observe LPN #1 to be sleeping while on duty but had observed them to be nodding off at the medication cart. - On the evening of 3/26/23, LPN #1 was worse than normal and something was definitely off. - LPN #1 was supposed to work until 3:00 AM on 3/27/23 and was sent home by LPN #5 when LPN #1 was found crawling on the floor. LPN #6 observed a video of LPN #1 on the floor, someone recorded it for professional purposes to have it investigated by Administration. - Before the video of LPN #1 sleeping at the medication cart was posted to social media, LPN #6 was talking to supervisors about it because of concerns LPN #1 was possibly under the influence. During a telephone interview with LPN #5 on 4/5/23 at 8:59 AM, they stated: - On 3/26/23, when they arrived for work for the 11 PM -7 AM shift, CNA #23 reported LPN #1 had been in the bathroom at least 45 minutes to one hour. - When LPN #1 came out of the bathroom, LPN #5 observed LPN #1 on the floor crawling around, reaching around for things that were not there. - LPN #1 got up from the floor and surrendered their keys to LPN # 5. LPN #5 did a narcotic count with LPN #1 and noted no narcotics had been signed out. LPN #5 entered the date and did not enter the times, as they did not know when the narcotics were administered. LPN #5 had to point and indicate to LPN #1 where to sign on the narcotic sheets, LPN #1 could not focus to sign as they were so out of it. The protocol for narcotics was to sign for each medication as it was administered to the resident, but LPN #1 did not sign out any narcotics during the shift. - LPN #5 asked LPN #1 if they were under the influence of something and LPN #1 was so incoherent LPN #5 could not understand them. LPN #1 exhibited signs and behaviors that made LPN #5 believe LPN #1 was under the influence of some substance. - LPN #5 spoke to the ADON in the morning (Monday 3/27/23) and provided a written statement. - The Administrator asked LPN #5 for a statement and LPN #5 told them it was already provided to the ADON. In an interview on 4/13/23 at 10:37 AM, the ADON stated sometime in early 3/2023 they received a call from RNS#16 at around 11:30 PM stating LPN #1 was nodding off, they took the medication keys from LPN #1, and relieved them of their duties. The ADON stated they were aware LPN #5 said they were calling 911 and did not know why 911 would be called for someone being tired. The ADON stated they should have questioned this situation more. The ADON had discussions with the DON and HR Coordinator related to LPN #1 being late by 2 to 4 hours and that LPN #1 was to work only 8-hour shifts, not double shifts. During an interview with the HR Coordinator on 4/13/23 at 12:08 PM, they stated LPN #1 had significant issues with arriving to work on time and they felt it was due to the LPN staying later into the overnight shift. LPN #1 was counseled for sleeping issues and the HR Coordinator felt those issues were related to working late or being tired. The HR Coordinator prepared the counseling forms related to LPN #1's tardiness on 3/6/23, 3/21/23, and 3/24/23 and would leave them for the ADON to complete. The plan for LPN #1 was not to work past their 3:00 PM-11:00 PM shift and the HR Coordinator was unaware of the reason the LPN continued to work past that shift. The supervisors made staffing decisions based on schedule and consulted with the DON and did not know if the supervisors would have known that LPN #1 was not supposed to work past the 3:00 PM -11:00 PM shift. The DON and ADON would have been responsible to communicate that to the supervisors. During an interview with the DON on 4/13/23 at 12:39 PM, they stated on 3/4/23 the DON received a text message from LPN #5 stating that RNS #16 relieved LPN #1 of their duties and the LPN was in the office. The DON stated they were never told by LPN #5 or RNS #16 of suspicions that LPN #1 was under the influence or impaired. The DON stated LPN #5 called 911 for LPN #1 as LPN #5 was dramatic. The DON stated they reviewed everything after this, there were no red flags and they found no issues. The plan was for LPN #1 to not work past their 3:00 PM-11:00 PM shift and was not scheduled past 11:00 PM. The DON was unaware of the reason LPN #1 continued to work past 11:00 PM. The HR Coordinator was to communicate to supervisors to ensure they knew not to schedule or allow LPN #1 to work past their 3:00 PM - 11:00 PM shift. The DON stated they were not made aware LPN #1 was sent home on the night of 3/26/ 23. The LPN had no knowledge of any issues until the social media post was brought to their attention on the morning of 3/27/ 23. There was no written documentation of a medication review or narcotic reconciliation from 3/3-3/4/23 or 3/26/23-3/27/ 23. The DON was unaware of the reason there was no documented narcotic reconciliation on 3/26/ 23. During an interview with the Administrator on 4/13/23 at 1:30 PM, they stated they could not recall being made aware of LPN #1 being sent home on 3/3/23-3/4/23 or of any concerns reported that LPN #1 was suspected of being under the influence. The Administrator could not recall any other concerns leading up to the 3/26/23 video of LPN #1 sleeping and stated the DON, ADON, and HR Coordinator would have followed up. The Administrator could not recall if anyone notified them LPN #1 was sent home on 3/26/23 prior to the video being released to social media. An untitled, unsigned statement received from the facility on 4/13/23 at 3:31 PM documented: 3/27/23, Unit 1, audit completed on descending individual patients' narcotic count sheets compared to the MAR (medication administration record) time span from 2/16/23 to 3/27/ 23. Medications were signed out appropriately and times aligned. All narcs were accounted for and no discrepancies. Residents were interviewed and stated they received their narcotics as dispensed. LPN #1 did not have access to the Omnicell (on-site medication dispensing machine). 10NYCRR 415. 26(a)ff reported people were taking videos and no one stepped in. - When LPN #5 arrived, CNA #23 reported LPN #1 had been in the bathroom at least 45 minutes to one hour and LPN #5 instructed CNA #23 to notify them immediately when LPN #1 came out of the bathroom. - When CNA #23 notified LPN #5 that LPN #1 had come out of the bathroom, they observed LPN #1 on the floor crawling around, reaching around for things that were not there. - Multiple staff recorded LPN #1 while they were on the floor, the 2 other LPNs that were on duty knew what was going on, and no one intervened. LPN #5 heard multiple evening shift (3:00 PM-11:00 PM) staff had taken videos of LPN # 1. - LPN #1 got up from the floor and surrendered their narcotics keys to LPN # 5. LPN #5 did a narcotic count with LPN #1 and noted no narcotics had been signed out. LPN #5 entered the date and did not enter the times, as they did not know when the narcotics were administered. LPN #5 had to point and show LPN #1 where to sign on the narcotic sheets. LPN #1 could not focus to sign as LPN #1 was so out of it. The protocol for narcotics was to sign for each medication as it was administered to the resident, but LPN #1 did not sign out any narcotics during the shift. - LPN #5 asked LPN #1 if they were under the influence of something and LPN #1 was so incoherent, LPN #5 could not understand them. LPN #1 exhibited signs and behaviors that made LPN #5 believe LPN #1 was under the influence of some substance. - LPN #5 sent a message to the ADON and/or the DON (could not recall if one of them or both) stating they were sending LPN #1 home and received no response. - When LPN #1 left the building, they sat in their car and kept hitting the horn, as if they were falling asleep and hitting their head, it was on and off. When LPN #5 approached the car, the engine was running, and LPN #1 left and parked in the parking lot across the street. LPN #5 attempted to notify the police and received no response. LPN #1 remained in the car for about 1 ??®??ó hours. - LPN #5 spoke to the ADON in the morning (Monday 3/27/23) and provided a written statement. The Administrator asked LPN #5 for a statement and LPN #5 told them it was already provided to the ADON. - The LPN added that when speaking to management, there were times they were instructed to refrain from saying they suspected LPN #1 was impaired. LPN #5 refused to refrain from expressing their suspicions because they did believe LPN #1 was impaired and was concerned about the safety of the residents. During an interview with LPN Unit Manager #13 on 4/13/23 at 10:15 AM, they stated at the end of a shift, the oncoming nurse was to verify the narcotic count with the off going nurse. LPN Unit Manager #13 saw the narcotic sheets about once weekly. If any discrepancies were noted, they would call the nurse and have them sign. The LPN Manager was unaware of any discrepancies in the narcotic count sheets. During an interview with the ADON on 4/13/23 at 10:37 AM, they stated they could not recall the date (identified as 3/3/23) when RNS #16 notified them around 11:30 PM of taking LPN #1's medication cart keys away due to them nodding off. The ADON asked if RNS #16 wanted them to go to the facility and was notified by LPN #5 that LPN #1 left before the ADON arrived. The ADON stated LPN #5 reported LPN #1 was sleeping, had their keys taken away, and LPN #5 could not wake them up. The ADON could not recall if LPN #5 reported calling 911 on 3/3/23 and did not think LPN #5 reported concerns that LPN #1 was under the influence. The ADON stated they should have questioned more people and handled it in the wrong manner, related to the night of 3/3/23 -3/4/ 23. The ADON had discussions with the DON and Human Resources (HR) Coordinator related to LPN #1 being late by 2 to 4 hours and that LPN #1 was to work only 8-hour shifts, not double shifts. During an interview with the HR Coordinator on 4/13/23 at 12:08 PM, they stated they were involved in employee discipline, attendance, and violations of general policies. LPN #1 had significant issues with arriving to work late and they felt it was due to the LPN staying later into the overnight shift. LPN #1 was counseled for sleeping issues and the HR Coordinator felt those issues were related to working late or being tired. The HR Coordinator prepared the counseling forms related to LPN #1's tardiness on 3/6/23, 3/21/23, and 3/24/23 and would leave them for the ADON to complete. The plan for LPN #1 was not to work past the 3:00 PM-11:00 PM shift and the HR Coordinator was unaware of the reason the LPN continued to work past that shift. The supervisors made staffing decisions based on the schedule and consulted with the DON. The HR coordinator did not know if the supervisors would have known that LPN #1 was not supposed to work past the 3:00 PM -11:00 PM shift. The HR Coordinator stated the DON and ADON were responsible to communicate that to the supervisors. During an interview with the DON on 4/13/23 at 12;39 PM, they stated: - they were unaware of a facility policy related to suspicions of substance abuse. - on 3/4/23, they received a text message from LPN #5 stating that RNS #16 relieved LPN #1 of their duties and LPN #1 was in the office. The DON stated they were never told by LPN #5 or RNS #16 of suspicions that LPN #1 was under the influence or impaired by. When LPN #5 reported they called 911, the DON was initially uncertain of the reason aside from LPN #1 being tired, and then stated LPN #5 was dramatic and likely why they called 911. The DON then stated they meant to say LPN #5 did the right thing by calling 911. On 3/4/23, the DON called LPN #1 and advised the LPN they were not to go to work until the DON and HR Coordinator spoke to them. On Monday (3/6/23), they met with LPN #1 who reported they had a migraine, took medication, and could not function. There was no investigation related to LPN #1 being sent home on 3/3-3/4/ 23. The DON stated they never suspected substance abuse. The plan was for LPN to not work past their 3:00 PM-11:00 PM shift and was not scheduled past 11:00 PM. The DON was unaware of the reason LPN #1 continued to work past 11:00 PM. The HR Coordinator was to communicate to supervisors to ensure they knew not to schedule or allow LPN #1 to work past their 3:00 PM - 11:00 PM shift. On the night of 3/26/23, the DON stated they were not made aware LPN #1 was sent home. The LPN had no knowledge of any issues until the social media post was brought to their attention on the morning of 3/27/ 23. The DON did not speak to anyone on the night shift from 3/26-3/27/23 and was not aware of the reason. There was no written documentation of a medication review or narcotic reconciliation from 3/3-3/4/23 or 3/26/23-3/27/ 23. The DON was unaware of the reason there was no documented narcotic reconciliation on 3/26/ 23. The DON expected any staff who observed concerns with LPN #1 sleeping at the medication cart to report immediately. During an interview with the Administrator on 4/13/23 at 1:30 PM, they stated they were unaware of a policy or protocol for suspicions of substance abuse by staff. They could not recall being made aware of LPN #1 being sent home on 3/3/23-3/4/23 or of any concerns reported that LPN #1 was suspected of being under the influence. The Administrator could not recall any other concerns leading up to the 3/26/23 video of LPN #1 sleeping and stated the DON, ADON, and HR Coordinator would have followed up. The Administrator could not recall if anyone notified them LPN #1 was sent home on 3/26/23 prior to the video being released to social media. The Administrator expected staff to report any concerns to a supervisor. The incident regarding the video was not reported to NYS DOH due to not being able to make a determination of neglect related to LPN # 1. During an interview with CNA #2 on 4/13/23 at 3:23 PM, they stated on the night of 3/26/23, they were notified by CNA #4 that LPN #1 was sleeping at the medication cart. CNAs #7 and 11 accompanied CNA #2 to the front of the building and observed LPN #1 asleep at the cart for approximately 10 minutes. LPN #1 would not respond when they tried speaking to them. CNA #2 recorded LPN #1 sleeping at the cart and sent the video to the HR Coordinator at 9:34 PM that evening. They received no response and notified the facility the following morning. CNA #2 reported to LPN #12 that night that LPN #1 was asleep at their cart and was told it was none of LPN #12's business. CNA #2 did not see any other LPNs in the building and was unaware of who else to notify to report the concern. An untitled, unsigned statement received from the facility on 4/13/23 at 3:31 PM, documented: 3/27/23, Unit 1, audit completed on descending individual patients' narcotic count sheets compared to the MAR (medication administration record) time span from 2/16/23 to 3/27/ 23. Medications were signed out appropriately and times aligned. All narcs (narcotics) were accounted for and no discrepancies. Residents were interviewed and stated they received their narcotics as dispensed. LPN #1 did not have access to Omnicell (on-site medication dispensing machine). 10NYCRR 415. 4(b)

Plan of Correction: ApprovedMay 14, 2023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Directed QA meeting held 5/4/23 Facility Administration received allegations against licensed practical nurse (LPN) #1 who was drowsy/sleeping while on duty. There was no documented evidence the facility immediately removed LPN #1 from having access to residents while investigations were pending, no documented evidence thorough investigations were completed to rule out neglect, and no documentation allegations were addressed immediately when received by Administration. Facility staff did not immediately report all concerns of possible resident neglect immediately to facility Administration. There was no documented evidence investigations were completed to ensure no misappropriation of resident narcotics occurred when LPN #1 was relieved of their medication administration duties when unable to perform those duties by facility staff. The facility did not report allegations of neglect to the New York State Department of Health (NYS DOH) until a completed investigation could be completed and neglect ruled out Facility Administration did not immediately remove LPN #1 from having access to residents while thorough investigations were ongoing and in process completed. Facility did not ensure the corrective action plan they developed to assist LPN #1 with performance issues example (limiting work hours) was implemented and carried out correctly. The administration did not complete a thorough investigation into narcotics reconciliation after being notified the nursing Supervisor removed LPN #1 from having access to medications after they suspected LPN #1 was under the influence??®??Ç Facility staff did not adhere to the social Networking/Cell phone policy while working. A video was posted to Facebook of LPN #1 not being able to perform her job duties??®??Ç Facility staff did not follow proper procedure for reporting staff concerns related to potential working conditions under suspected under the influence of drugs and or alcohol??®??Ç Facility did not have a policy/procedure for facility staff to guide them when other staff where suspected to be under the influence of alcohol/drugs 100% audit of all resident's individual narcotic sheets for dates 3/3/23-3/26/23 completed, all scheduled, and prn narcotics were appropriately accounted for on narcotic sheets 100% audit of all resident's grievances from 3/26/23-2/26/23 no identified care issues related to LPN #1 Partnership with the Statewide Peer Assistance for Nurses was initiated for facility staff to assist and foster a collaborative relationship with reporting/recognizing staff substance abuse The DNS, ADNS, and Administrator have been re-educated on CMS guidance F600 by the Corporate Administrator and QA consultant RN. The following measures and/or systemic changes have been developed/implemented in order to ensure that the deficient practice will not reoccur: Facility policy on Social Networking has been reviewed and appropriate 100% of facility staff educated on the facility Social Networking policy Facility policy on Cell Phone has been reviewed and appropriate 100% of facility staff educated on the facility Cell Phone policy Facility policy on Emergency Notification of Management instituted. 100% of facility staff educated on the facility Emergency Notification of Management policy 100% of facility staff educated on the facility timely notification of Abuse /Neglect/Mistreatment Facility Corporate Compliance policy was reviewed and no changes 100% of facility staff educated on Corporate Compliance including the confidential phone number for staff, residents, visitors to report concerns Partnership with the Statewide Peer Assistance for Nurses ongoing Facility instituted a new policy on Purposeful rounding; specifically, regarding staff changes in condition Licensed Nursing staff to be educated Purposeful rounding; specifically, regarding staff changes in condition 100% of facility staff educated on specific sections of the employee handbook covering Code of Conduct, the problem-solving procedure, Code of Ethics, Drug and Alcohol 100% of facility staff educated on employee handbook covering Code of Conduct, the problem-solving procedure, Code of Ethics, Drug and Alcohol Facility instituted a new policy Suspicion of Drug/[MEDICAL CONDITION] and testing.??ÿ Licensed Nursing staff to be educated on the new policy Suspicion of Drug/[MEDICAL CONDITION] and testing specifically once a concern/complaint is made to administration /management the staff member is removed from duty immediately pending a thorough investigation. Facility Policy on Controlled Substance; Access to Narcotic storage and locked drug areas reviewed and revised specifically to include- Narcotic sheets shall be stored in a binder and medical records will collect monthly to ensure secure storage Licensed staff educated on Controlled Substance; Access to Narcotic storage Facility policy on Controlled Substance; Access to Narcotic storage outlines a process for investigating narcotic count discrepancies, policy remains appropriate. Licensed Nursing staff will be re-educated on investigating narcotic count discrepancies per Controlled Substance; Access to Narcotic storage Medical Records to be educated on the new process of ensuring proper storage of narcotic sheets Education provided by Consultant RN 5/5/23 2130,2315, 5/6/23 1430,2315,5/7/23,1415,2130, 2345, 5/8/23 1315 Targeted staff all department heads, all licensed nursing staff The DNS, ADNS, and Administrator have been re-educated on CMS guidance F600 by the Corporate Administrator and QA consultant RN. The DNS, ADNS, and Administrator have been educated on the Discipline -Corrective Action policy; specifically, as it relates to removing staff from work pending allegations immediately protecting residents. The DNS has been educated on her job description, review of policy and procedures specifically Social Networking, Cell Phone, Emergency Notification of Management, Abuse-Investigating and reporting, Corporate Compliance, Controlled Substance; Access to Narcotic storage and investigating narcotic discrepancies, Suspicion of Drug/[MEDICAL CONDITION] and testing, on Purposeful rounding; specifically, regarding staff changes in condition, employee handbook covering Code of Conduct, the problem-solving procedure, Code of Ethics, Drug and Alcohol . 4) The following monitoring activities will be/have been implemented in order to ensure that the deficient practice will not reoccur: QA consultant will review daily with Administration for four weeks all staff suspicion/concerns that is a violation of staff behavior related to the employee handbook ??®??Ç Follow-up by QA Committee for data analysis & identified issues ??®??Ç Revision of facility policies & procedures as needed Responsible Party: Director of Nursing