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Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: July 29, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the abbreviated survey (NY 143) the facility did not ensure residents were free from abuse, neglect or mistreatment for 1(Resident #1) of 3 reviewed. Specifically, on [DATE], Registered Nurse Supervisor#1 observed Certified Nurse Aide #1 pushing Resident #1 who is severely cognitively impaired, from the front in the hallway. Resident #1 stumbled backwards but did not fall. Certified Nurse Aide #1 was asked why they pushed the resident, and they responded, because he does not listen. The findings are: The Facility Policy titled Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting last revised on [DATE] documented that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. 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. Residents/clients must not be subjected to abuse by anyone, including , but not limited to staff, other resident/clients, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, friends, students, interns or other individuals. Resident #1 was admitted with [DIAGNOSES REDACTED]. The [DATE] Quarterly Minimum Data Set (MDS) an assessment tool documented that Resident #1 had severe impaired cognition and required supervision with eating, bed mobility, transfers and ambulation. The resident needed moderate assistance with shower/bathing and toileting and had no behaviors or rejection of care. The Abuse Care Plan dated [DATE] and revised on [DATE] documented that Resident #1 was at risk for harm and abuse related to self-directed or other directed, dementia, mood disorders, and [MEDICAL CONDITION]. Interventions included encouraging resident to verbalize cause for aggression, encouraging resident to report any negative interactions. Social work to provide support, supportive counseling. Psychiatry and psychology consultations as deemed necessary. The [DATE] Risk for Abuse care Plan documented that Resident #1 was at risk and a potential victim of abuse as evidenced by primary [DIAGNOSES REDACTED]. Interventions included providing emotional support, and Psychiatric and Psychological evaluations as needed. The Internal Investigation dated [DATE] documented that on [DATE], Registered Nurse Supervisor #1 observed Certified Nurse Aide #1 pushing Resident #1 from the front. Resident #1 wobbled backwards but did not fall. The Registered Nurse Supervisor immediately removed Certified Nurse Aide #1 from Resident #1's care and directed them to the medication room and assessed Resident #1 to ensure that they were not hurt. No visible injuries noted. Certified Nurse Aide #1 was immediately suspended pending investigation. 911 was called. The facility concluded that based on their investigation the allegation of abuse was substantiated because the incident was witnessed by Registered Nurse Supervisor #1, who observed Certified Nurse Aide #1 shoving the resident causing Resident #1 to stumble backwards. The Certified Nurse Aide #1's written statement dated [DATE] documented that while they were watching the other residents around the nurse's station, Resident #1 was flickering the light switch on and off and the other residents were complaining about the light. Certified Nurse Aide #1 documented they went over to Resident #1 and took them by the arm and moved them from the light switch. When Registered Nurse Supervisor #1 observed them touching Resident #1, they asked them why they did that. Certified Nurse Aide #1 documented Resident #1 was annoying the other residents. Attempt to reach Certified Nurse Aide #1 on [DATE] at 11:11 am was unsuccessful. Unable to leave a voicemail. During an interview on [DATE] at 12:23 PM, Registered Nurse Supervisor #1 stated that on [DATE] at approximately 8:10 pm during rounds they were coming from the Weinberg unit facing NE2 unit, and as they pushed the door, they saw Certified Nurse Aide #1 push Resident #1 and the resident stumbled backwards but did not fall. Registered Nurse supervisor #1 stated that they did not observe Resident #1 playing with light switches. Registered Nurse supervisor #1 stated that they went over to Resident #1 to make sure that they were ok. There were no signs of distress observed. Certified Nurse Aide #1 was brought into the medication room and asked about the incident. Certified Nurse Aide #1 stated Resident #1 does not listen. Registered Nurse Supervisor #1 stated that they immediately called the administrator on duty, and they received instructions to send Certified Nurse Aide #1 home. Registered Nurse Supervisor #1 showed surveyor the exact area where the alleged abuse happened which was in front of room [ROOM NUMBER] (linen chute) on unit ne 2. During an interview on [DATE] at 12:45 pm, the Administrator stated that they are no video footage for the incident because there are no cameras in the hallway. Cameras are only located at entrances, exits, the loading dock, the kitchen and basement corridors. During an interview on [DATE] at 12:47 pm, the Director of Nursing stated they received a call from the Assistant Director of Nursing after the incident that Certified Nurse Aide #1 was sent home because they allegedly shoved a resident. The Director of Nursing stated that based on the facility investigation concluded it was abuse because Certified Nurse Aide #1 did not deny that they shoved Resident # 1. The incident was also witnessed. The Director of Nursing stated that they have reached out to the facility lawyers and Certified Nurse Aide #1 will most likely be terminated. The Director of Nursing stated that all facility staff are being educated on abuse and rough handling of residents. During an interview on [DATE] at 5:13 PM, the Director of Nursing stated that they have already drafted up the paperwork for the termination of Certified Nurse Aide #1 and Certified Nurse Aide #1 will not be re hired. 10NYCRR 415. 4(b)arm band was the hospital's red arm band and not the facility's. Because the red color was the same RN #1 assumed the red arm band was the facility's DNR red arm band. RN #1 stated that at 11:57 AM they (RN #1) texted the PMD Sorry Dr. but resident is not DNR, but (resident) is clearly gone, the patient is full code per (their) wishes. At 11:58 AM the PMD responded via text yes (resident) is full code. RN #1 stated the PMD did not compel' RN #1 to do CPR. RN #1 stated if that red arm band was not present on the resident then, they would have started CPR. Once they (RN #1) identified that Resident #1 was a full code (CPR) RN #1 felt there is no reason for them (RN #1) to start CPR and believed that Resident #1 was clinically gone and it was too late. 415. 3(d)(iii) | Plan of Correction: ApprovedAugust 29, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-678 Directed Plan of Correction was done by consultant: CMS Compliance Group, Inc 68 south Service Road, Suite 100 Melville, NY 1. The following actions were accomplished for the residents identified in the sample: Resident #1 expired; therefore, no corrective action could be implemented. RN#1 The identified licensed nurse who did not initiate CPR was suspended [DATE], returned to duty on [DATE] and received additional education specific to identification of a resident's advance directives and initiation of resuscitative measures when appropriate. The DNS/designee identified all licensed nurses who signed the MAR indicated [REDACTED]. On [DATE] the facility policy and procedure Admission Policy and Procedure??ÿ was reviewed by Administration and revised to include that the admission nurse is responsible for ensuring that admitted residents are wearing the proper CIH armbands and that bands applied by a previous facility are removed. The nursing supervisor is responsible for verifying that all admissions/readmissions are wearing the correct armbands. On [DATE] the facility policy and procedure Do Not Resuscitate??ÿ (DNR) was reviewed by Administration and revised to include an additional step of including documentation on the MAR indicated [REDACTED]??ÿ every shift. The above additional order was entered on [DATE] for all resident with current status of DNR. On [DATE] the facility policy and procedure Arm Bands??ÿ was reviewed by Administration and revised to indicate the admission nurse's role in removal of previously placed ID bands and placement of CIH issued bands. New orders were added into the EMR for the assigned nurses to check the presence of name identification bands as well as red colored arm bands indicative of DNR status every shift and document same on the MAR. On [DATE] the facility policy and procedure Resuscitation Measures??ÿ dated [DATE] was reviewed by the Administration and no revision was indicated. All responsible staff were educated by the Staff Development Educator/designee on the revised policies and procedures starting on [DATE] and 100% compliance has been met with this initial education. 2. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents with an advance directive order have the potential to be affected by the same practices. On [DATE] the facility completed a full house audit to confirm Advance Directive/code status was correctly identified and consistent with physician orders [REDACTED]. The audit was completed daily for one week, as of [DATE] was completed three times a week and as of [DATE] will continue twice a week. The facility form DNR/CPR Nursing Response??ÿ will continue to be used for all supervisor STAT events. Effective [DATE], the facility implemented a form to utilize for Supervisor Stat??ÿ Drills. The Staff Educator/Supervisor/designee are responsible for completion of this form and forwarding the completed form to the DNS/designee. All responsible staff have received education on completion of this form. On [DATE] the facility policy Do Not Resuscitate (DNR) was reviewed by Administration and was revised to reflect the removal of colored dots DNR identifiers (red dots) from the spine of resident paper charts and the name plate above the bed. The identifiers were removed from both areas on [DATE] for all residents who have a DNR. On [DATE], the DNS/designee reviewed the BLS/CPR certification of all licensed nurses to ensure scheduled licensed nurses are qualified to provide basic life support, including CPR to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident's advance directives, and physician orders. All licensed nurses will be CPR/BLS certified as of ,[DATE]/ 2022. The Staff Educator will continue monitoring the CPR/BLS certification of all nurses. As per the Directed In-service, the Outside Consultant initiated education for all clinical and non-clinical staff on [DATE] related to CPR and this education will continue until all staff, including PT/PD and agency staff, have received the mandatory education on F-678 protocols. Education will emphasize the need to ensure residents are wearing appropriate CIH issued identification bands, initiate a supervisor STAT??ÿ during emergency situations, the licensed nurses' responsibility to verify code status prior to initiating CPR and checking for DNR identifiers (red armband) every shift. 3. The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: Effective [DATE], Advance Directives discussion will be included during the daily morning report to identify new admissions/readmission code status as well as changes to resident's code status and/or life-sustaining orders. Residents leaving the building for outside appointments will continue to travel with an envelope with information inclusive of code status; escorts are informed of the same. All new staff/agency staff will continue to be educated by Staff Development Educator/designee on the identification of code status during their orientation and the Supervisor STAT procedures. All staff will be re-educated annually as well as on an as needed basis. Follow-up monitoring will be completed by the Staff Development Educator and Nursing Supervisors to ensure staff understands these protocols and their responsibility to adhere to them. The DNS/designee will continue to monitor information shared at Morning Report to identify any issues/concerns related to CPR and Advance Directives. Immediate investigation and implementation of corrective actions will be implemented, such as staff reeducation or review of current protocols for any additional corrective action, as needed. The DNS/designee will continue to monitor daily staffing to ensure that properly trained personnel (and certified in CPR for Healthcare Providers) are available immediately (24 hours per day) to provide basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident's advance directives, and physician orders. Nursing management will continue to monitor and maintain a record of licensed nursing staff who are trained and qualified to provide CPR and are able to demonstrate current competency. The DNS/designee will conduct a review of all expirations following a STAT??ÿ event to assess compliance with all new and revised policies and procedures related to basic life support. Review activities will include confirming code status and staff following advance directives related to CPR, assessing staff's timely and appropriate response to a Code, as well as assessing if responsible staff completed the documentation accurately and that expiration notes and other clinical assessment notes are entered in the medical record. 4. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan, a Quality Assurance Committee meeting co-chaired by the Outside Consultant was held on [DATE] to discuss and conduct a Root Cause Analysis (RCA) of this deficiency. The facility has developed audit tools to monitor compliance with staff adherence with Admissions/DNR/ Arm bands/Resuscitation Measures policies and procedures. The Director of Nursing/designee will conduct a full audit (100%) of Advanced Directives/physician orders/verification of ID bands weekly for one month, then monthly for three months to determine compliance and consistency with completion of required documentation. Following the initial 100% auditing of Advance Directives, physician orders/ verification of placement of ID bands, the Director of Social Work/designee will audit all residents monthly for six months. The Director of Social Work/designee will report Advance Directives and Physician orders [REDACTED]. Corrective actions, such as staff reeducation, will be implemented as needed. The Director of Social Work/designee will report all Advanced Directive and Physician order [REDACTED]. Following this six-month period, the QAPI Committee will determine the frequency thereafter. The Director of Nursing/designee will audit all Stat??ÿ events to assess compliance with CPR being initiated as per a resident's Advance Directives and Physician orders. All Code event audit findings will be reported to the Administrator and Medical Director following completion of the audit. Immediate corrective actions, such as further investigation of the event or staff reeducation, will be implemented as needed. The Director of Nursing/designee will report all Stat??ÿ event audit findings to the QAPI Committee quarterly for evaluation and follow-up corrective action. Ad hoc committee meetings will be convened to conduct an RCA when there is staff failure to adhere to facility protocols related to initiation of CPR. The Staff Educator/designee will utilize the Advance Directives/CPR/Code Status questionnaire to determine staff knowledge of these protocols. Initially all staff will complete the questionnaire following participation in mandatory education. The Staff Educator/designee will then audit 20% of staff monthly for the next three months to determine staff's knowledge of the above protocols. Licensed nurses will be included in all audit samples. Reeducation will be provided as needed. The Staff Educator will report Staff Knowledge of Advance Directives/CPR/Code Status to the QAPI Committee quarterly for the next six months for evaluation and follow-up. At the end of the six months, the QAPI Committee will determine the need for ongoing auditing and frequency thereafter. The Staff Educator will conduct Stat??ÿ drills on a quarterly basis for the next six months on all shifts in different locations and utilizing random scenarios to assess the staff's compliance and understanding of correct implementation of CPR when indicated. All Stat??ÿ drill findings will be discussed at the QAPI Committee meeting for evaluation and follow-up actions. Person Responsible: Director of Nursing Compliance Date: [DATE] |