NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
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 # | 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?é?À 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?é?À 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?é?À 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 residents 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 residents 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.?Ø 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 ?é?À Follow-up by QA Committee for data analysis & identified issues ?é?À 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: N/A
Citation Details 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 | 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?é?À 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?é?À 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?é?À 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 residents 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 residents 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.?Ø 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 ?é?À Follow-up by QA Committee for data analysis & identified issues ?é?À Revision of facility policies & procedures as needed Responsible Party: Director of Nursing |