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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 14, 2023
Corrected date: June 13, 2023
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) | 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? 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? 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? 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 residentÆs 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 residentÆs 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 ôSuspicion of Drug/[MEDICAL CONDITION] and testing.ö Licensed Nursing staff to be educated on the new policy ôSuspicion 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 ? Follow-up by QA Committee for data analysis & identified issues ? Revision of facility policies & procedures as needed Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 14, 2023
Corrected date: June 13, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the abbreviated survey (NY 544), the facility failed to ensure residents had the right to be free from neglect for 37 of 89 residents (Residents #1-37). Specifically, - 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. - The facility did not report allegations of neglect to the New York State Department of Health (NYS DOH) as required. Findings include: The facility policy Controlled Substance: Access to Narcotics Storage and Locked Drug Areas effective 10/2019 documented: - At the beginning and end of each shift, all narcotics and controlled substances would be accounted for by having 2 nurses (one from the current shift and one from the oncoming shift) count narcotics and sign the appropriate accountability records. - any discrepancies would be reported to the Nursing Supervisor immediately; the off-going nurse must not leave the facility until the Nursing Supervisor had addressed the situation by either finding the missing narcotic or starting an investigation into the matter. - If the narcotic key must be given up before the end of the shift, for any reason, the nurse giving up the key must count the narcotics with the nurse receiving the key, and this must be documented on the narcotic change of shift sheet. - Anytime the narcotic keys were exchanged between nurses, the narcotics must be counted and documented on the narcotic shift change sheet. The facility policy Reporting Resident Abuse, Mistreatment, Neglect, or Misappropriation of Property reviewed 4/2021 documented: - Whenever there was reasonable cause to believe that resident physical abuse, mistreatment, neglect, or misappropriation of property had occurred by staff or a family member, the suspecting individual must call the NYS DOH. - Alleged violations and injuries of unknown source must be reported immediately, but no longer than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. - The results of all investigations would be reported to the DOH in accordance with state laws within 5 working days of the incident. 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 identified as 3/3/23), they removed LPN #1 from the medication cart because they suspected LPN #1 to be under the influence. RNS #16 stated they absolutely thought (LPN #1) was under the influence of something based on how (they) were acting, nodding off. RNS #16 stated they called the Assistant Director of Nursing (ADON) and asked them to come to the facility to observe LPN #1's condition because they suspected LPN #1 to be under the influence. The ADON did not arrive before LPN #1 left. LPN #5 called 911 because they were worried LPN #1 was not safe to drive. LPN #1's entire medication pass (3 PM to 11 PM shift) had not been completed when LPN #1 left. RNS #16 stated they spoke to the ADON the following day and reiterated their concerns that LPN #1 was under the influence while working. LPN #1's time sheet documented they punched out at 12:03 AM on 3/4/23. During a telephone interview on 4/5/23 at 8:59 AM with LPN #5 they stated on 3/3/23, when they arrived to work for the 11:00 PM to 7:00 AM shift, LPN #1 had been relieved of their medication cart duty by RNS #16. LPN #5 observed LPN #1 in the front vestibule of the building and stated LPN #1 appeared to be under the influence. They stated LPN #1 was incoherent. LPN #5 notified the ADON they thought LPN #1 was under the influence and asked the ADON to come to the facility. LPN #1 left the building and LPN #5 was concerned about their ability to drive so they notified 911. LPN #5 stated they notified the Administrator and Director of Nursing (DON) via text message stating they sent LPN #1 home and that they notified the police due to the suspicion LPN #1 was under the influence. The DON replied asking if LPN #1 was on the schedule for the weekend and then the DON called LPN #5 and asked them to take LPN #1 off the schedule for the weekend until the DON could talk to LPN #1. LPN #5 stated they were concerned about the safety of the residents and the LPN's ability to drive, as they were completely incoherent. The audio recording of the call from the facility to the county 911 center on 3/4/23 at 12:14 AM was reviewed. The call was made by LPN #5 who identified themselves by name and reported the following: - LPN #1 was on the road and they suspect (they) are inebriated. LPN #5 stated LPN #1 was nodding out at the medication cart. - LPN #5 reported LPN #1 was sleeping for numerous hours, they pulled LPN #1 from the medication cart because they suspected LPN #1 was under the influence, told LPN #1 to sit in the office to sleep, and they contacted the ADON, who was on the way to evaluate the situation when LPN #1 took off. - LPN #5 stated they wanted the officers to keep an eye out for LPN #1, as they were definitely a danger, they could not keep LPN #1 at the facility, and LPN #1 was barely even coherent to walk. LPN #5 stated they tried to convince LPN #1 to stay, and LPN #1 just left. 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 at the facility. The ADON was notified. LPN #5 called and left a voicemail for the ADON to let them know LPN #1 left prior to the ADON's arrival. LPN #5 tried to keep LPN #1 there, but they went out the back door. Police were notified by LPN #5. - The DON's text message reply stated 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; the LPN was relieved of their medication cart, and LPN #1 was resting in the front office. The DON took LPN #1 off the schedule for the weekend and spoke to LPN #1 the following Monday (3/6/23). LPN #1 reported they took migraine medication which caused them to be drowsy. The LPN appeared without any impairments and clear communication and was placed back on the schedule. There was no documented evidence an investigation was completed to address the concerns as reported by RNS #16 and LPN #5 on 3/4/23, including a medication review, narcotic reconciliation, or statements from staff to rule out resident neglect. On 3/28/2023, complaints from an anonymous staff member and multiple third parties were reported to the 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. In addition to the third-party complaint, on 3/28/23, the facility reported that on 3/28/2023 at 12:00 PM, they became aware of a video posted to social media which showed the legs of Resident #4 in the background. They reported certified nurse aide (CNA) #2 was the accused staff member who took the video. The facility report contained no documentation related to allegations of neglect against LPN #1. On 3/28/2023 at 5:22 PM, a surveyor arrived at the facility and observed the staff member from the video in the front office. The DON stated at that time, the staff member in the video was LPN #1 and LPN #1 was there to provide a statement. The DON offered the following information to the surveyor on arrival: - The video posted on social media was recorded on 3/26/2023 between 9:00 PM and 9:30 PM and was recorded by CNA #2 who told the facility about the video on 3/27/23. - At 8:30 PM on 3/26/2023, the DON spoke with LPN #1 regarding Resident #23's catheter and the DON had no concerns with LPN #1's demeanor. LPN #1 followed directions and spoke clearly. - LPN #1 reported that after speaking with the DON on 3/26/23, they received a disturbing telephone call and put their head down at the medication cart in response to the call. - After they received the disturbing call, LPN #1 called 911 for Resident #23, sent the resident out, and interacted with emergency medical services (EMS). - The DON felt LPN #1 was reacting to disturbing news from the telephone call when they were observed on the video bending over. - Resident #4 told them they witnessed the recording of the video when LPN #1 bent over at the medication cart. - The facility initiated an investigation and talked with all staff who worked on 3/26/2023. On 3/28/2023 at 6:15 PM, Resident #4 stated in an interview, they witnessed LPN #1 at the medication cart on 3/26/2023 when other staff members recorded LPN #1 on their phones. Resident #1 stated there were at least 2 staff recording but the staff were new, and they did not know their names. Resident #4 saw LPN #1 put their head down and thought they had a headache. They stated LPN #1 gave them medications later in the shift and they did not think there were any issues with LPN #1 at that time. On 3/28/23, the DON provided a timeline and statements to the surveyor related to the 3/26/23 video posted to social media. The DON's timeline documented: - on 3/27/2023 at 8:30 AM, facility Administration was notified of the video of LPN #1 on social media and started interviewing staff. - On 3/28/2023, LPN #1 wrote a statement about the events on 3/26/2023 and documented they worked the evening shift after a long day the day prior. They received a disturbing personal call while working so they brought the medication cart to a quiet area away from residents. While getting ready to complete the second part of the medication pass, 2 CNAs told LPN #1 that Resident #23 pulled out their catheter. LPN #1 called the DON to get instructions and called 911 for the resident. While waiting for EMS, LPN #1 put their head down for a quick minute. LPN #1 was not aware they were being recorded. LPN #1 then went to the copy machine to print records for the resident being sent to the hospital and talked with EMS. After EMS left, LPN #1 finished their medication pass. - On 3/27/2023, CNA #2's statement documented last night they worked with LPN #1 and was told by CNA #4 that LPN #1 was not passing medications and appeared to be under the influence. CNA #2 documented LPN #1 was asleep and not answering staff when they asked them questions. A second investigation written by the DON, provided by the facility, documented it was a Video Investigation on 3/28/2023, and included: - At 12:00 PM, the facility's {Social Media} Administrator was notified that a video was tagged to the facility's Facebook page that was a video of LPN #1 falling asleep at the nursing station. - A narcotic audit was done for 3/26/2023 and no issues were identified. - CNA #3's statement dated 3/29/23 documented on 3/26/23, LPN #1 seemed extremely tired when they came in for their shift and kept falling asleep at their (medication) cart. CNAs #3 and 4 kept talking to LPN #1 to keep them awake. CNA #3 woke up LPN #1 to send a resident to the hospital. - CNA #4's undated statement documented on 3/26/23, LPN #1 seemed extremely tired around dinner time and started nodding off and falling asleep at their (medication) cart. CNA #4 along with CNA #3 would wake up LPN #1 and keep the LPN company so they would not fall asleep. - CNA #2 self-terminated on Tuesday 3/35/23 (3/28/2023). - No residents were affected, and no negative outcomes were found. - The investigation was signed and dated by the DON on 3/31/2023. There was no documented evidence in the investigation of a medication administration review or documentation of the referenced narcotic audit that occurred. The Change of Shift Controlled Medication Count sheet did not contain any documentation that nurses completed a shift to shift count on 3/26/23 for the day, evening, or night shifts. No nurses signed the sheet as counting off the narcotics when passing the keys to one another on that date. The audio recording of the call from the facility to the county 911 center on 3/26/23 at 8:55 PM (for a resident to be transferred) was reviewed. The call was made by LPN #1 who identified themselves by name and included: - LPN #1 stated a resident had removed their suprapubic catheter (urine is drained directly from the bladder through a small opening and tubing). - The 911 operator asked how old the patient was, LPN #1 replied (they're) ok. - the 911 operator repeated the question and LPN #1 then answered the question. - The 911 operator asked if the resident had been seen by a nurse or physician in the last 2 hours, the LPN replied no. - When asked if the facility had a nurse on staff, LPN #1 replied Oh yeah, I mean, I thought you said doctor. - The 911 operator repeated nurse or doctor, the LPN replied yes, yeah. The LPN's speech pattern was delayed, and LPN #1 was slow to respond to questions asked by the 911 operator. During an interview with emergency medical technician (EMT) #24 on 4/26/23 at 4:19 PM, they stated they responded to the facility on [DATE] to pick up Resident #23 at approximately 9:00 PM. Upon arrival, the nurse described as LPN #1 directed them to the resident's room. The EMT addressed the resident in the room, and that resident was not aware of the reason the EMT was there. LPN #1 did not follow them to the room or provide any information. After speaking to the resident, the EMT realized it was not the resident they were there to transport, and their partner went to the nurse's desk to find out where Resident #23 was. The EMT then heard another unidentified nurse in the hall directing their partner to the correct resident's room. The EMT reported LPN #1 seemed confused as to the reason they were there and did not have any further interaction with them. A timeline of LPN #1's employment signed and dated by the DON On 3/29/2023 documented: - LPN #1 started working at the facility 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 and 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. LPN #1 reported they were sleeping prior to driving home. - 3/24/2023, spoke with LPN #1 about the upcoming weekend and the 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. 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 PM-11 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 no one else signed the forms. The spot for signatures of the person completing the discipline, a witness, Manager, and Administration were blank. On 4/3/2023 at 11:26 AM, CNA #3 stated in an interview, they worked on the evening shift on 3/26/2023 and when LPN #1 came in they looked fine but when they got to the medication cart, they started dozing off. When CNA #3 talked to LPN #1, they stayed awake but when left alone, LPN #1 fell asleep. After dinner, LPN #1 continued to fall asleep and aroused when CNA #3 said their name. After the video was taken, LPN #1 went to the copy machine to prepare papers for a resident going out and CNA #3 saw them dozing off at the copy machine. CNA #3 reported these concerns to LPN #6 who said to keep an eye on LPN #1 and keep them awake by talking with them. In an interview on 4/3/23 at 1:49 PM, LPN #6 stated on 3/26/2023, they worked on the other side of the facility from LPN #1 and: - LPN #6 only worked with LPN #1 a few times and 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 report the occasions when LPN #1 was absent during their shift, as LPN #6 did not want to make assumptions about LPN #1. - LPN #6 observed LPN #1 to be nodding off at the medication cart before. - 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 concerns LPN #1 was possibly under the influence. - On 3/26/23, LPN #1 was not able to be found much of the shift and this was common, LPN #1 was often in the bathroom or out in their car. When LPN #1 could not be found, staff reported to LPN #6 and LPN #6 would check on LPN #1's residents. - On 3/26/23, LPN #1 almost sent out the wrong resident to the hospital and LPN #6 intervened. - There may have been talk about LPN #1 sleeping at the medication cart on 3/26/23 but LPN #6 did not know it was as bad as what was later observed in the video that was posted to social media on 3/27/23. Staff only reported that it was hard to find LPN #1. - After LPN #1 was relieved of their duties on 3/26/23, the LPN stayed in their car until about 3:00 AM, intermittently hitting the horn. Residents complained of the lights shining in their windows from the vehicle. During a telephone interview with LPN #5 on 4/5/23 at 8:59 AM, they stated: - On 3/26/23, they arrived to work for the 11:00 PM -7:00 AM shift and LPN #1 was scheduled to work until 3 AM. Staff 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 ½ 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 Plan of correction not approved or not required |