Cooperstown Center for Rehabilitation and Nursing
November 30, 2018 Complaint Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: January 10, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case# NY 222), the facility did not ensure that each resident received adequate supervision to prevent accidents for two (Resident #s 6 and 8) of ten residents reviewed. Specifically, for Resident #8, who had a history of [REDACTED].#6 and other residents, the facility did not ensure supervision was provided for Resident #8 on 7/18/18, resulting in a physically aggressive altercation with Resident #6. This is evidenced by: The Policy and Procedure (P&P) titled Resident to Resident Altercations with a review date of 3/2017, documented the P&P's purpose was to identify all residents who were at risk for having an altercation with another resident and to proactively monitor behavior to prevent recurrence. There were to be ongoing observations by all staff to identify potential/actual concerns. If a resident to resident altercation did occur, staff were to immediately separate residents and remove residents from harm's way. The event was to be documented, giving details on when and where it happened, who was involved, what happened, and why it happened. The Charge Nurse/Designee was to place a note in the clinical record(s) stating the nature of the altercation, and a description of the event with the following statement Facility policy implemented. Resident #8 This resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident's cognitive skills for daily decision making were poor, and cues and or supervision were required. The Psychological Services Diagnostic Evaluation dated 7/24/18 documented the resident had severely impaired cognition. A Care Plan Activity Report (CCP) titled Behaviors/Mood State/Cognition initiated on 1/23/17 by the Director of Social Work (SW #1), documented the resident had a [DIAGNOSES REDACTED]. The resident patrolled the unit looking for a friend in need of help, and sometimes got upset if he was unable to help someone. The CCP did not include interventions for supervising the resident. The CCP titled Resident to Resident Altercation (Aggressor) initiated on 3/9/18, documented Resident #8 was the aggressor in a resident-to-resident altercation on 12/31/17 at 2:00 AM. Resident #8 heard another resident calling for help and went to try to help. The other resident's yelling overstimulated him and he began hitting her in the head. The CCP did not include interventions for supervising the resident. The CCP titled Resident to Resident Altercation (Aggressor) updated on 3/19/18, documented that on 3/14/18 at 4:20 PM Resident #8 was noted to be aggressive toward another resident. He was kicking the other resident. The facility was going to talk to staff about having someone monitoring the area at all times. The CCP did not include interventions for the supervision of the resident. The CCP titled Resident to Resident Altercation (Aggressor) updated on 4/11/18, documented an intervention for enhanced supervision in the afternoon, and engage in an activity as the resident allows. Enhanced supervision was not defined in the CCP. The Incident and Accident (I&A) Form dated 7/18/18 at 5:00 PM, documented Resident #8 was involved in a physical altercation with Resident #6 in the front hall activity area. The incident was not witnessed. Video footage was reviewed by the facility and revealed an altercation transpired between the residents. An Investigation Form dated 7/20/18, for the incident dated 7/18/18 at 4:53 PM, documented Resident #6 was found on the floor in the common area and complained of right leg pain. Stat x-ray revealed a [MEDICAL CONDITION]. No staff witnesses were present. Several residents were seated in the common area. Video camera review revealed an altercation between Resident #'s 8 and 6. Resident #8 slapped another resident. Resident #6 backhanded Resident #8 two times. Resident #8 pulled Resident #6 up from her chair by her wrists, both residents walked holding onto each other, Resident #6 pulled away, lost her balance and fell to the floor. Resident #8 lost his balance and fell on to Resident #6's feet and then rolled off the resident. The CCP Resident to Resident Altercation (Aggressor) updated on 7/23/18, documented an IDT (interdisciplinary team) review of the incident on 7/18/18. Video footage revealed Resident #8 was the aggressor in an altercation with two other residents. Resident #8 was noted to make contact to the left side of the two resident's cheeks with his open right hand. Resident #8 then lifted one of the female residents out of her wheelchair by her left arm, stumbled/walked some with the female resident, and when he let go of the resident, she lost her balance and fell . Resident #8 lost his balance and fell , hitting his head against the wall. A Psychological Services Diagnostic Evaluation dated 7/24/18, documented Resident #8 had recently been physically aggressive toward another resident, which resulted in a serious injury, and Resident #8 could not recall the incident. During the evaluation, Resident #8 was cooperative and pleasant, however, was easily distracted by noises and became visibly irritated with loud noises. His irritation quickly abated when the noises ceased. Resident #8 exhibited the following signs and symptoms: poor executive functioning (inability to self-monitor and control behaviors), declining memory, disturbance of consciousness, current and historical aggressive, combative and violent behaviors, and unpredictable mood swings. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severely impaired cognition. The CCP Resident to Resident Altercation (Aggressor/Victim) initiated on 1/4/18, documented Resident #6 had the potential to be both an aggressor and victim in a resident-to-resident altercation. Resident #6 had dementia, however the resident was more oriented than many of the residents around her. Resident #6 had the potential to become frustrated with other residents and would let them know. This frustration might also agitate other residents. The CCP did not include interventions for the supervision of the resident. The CCP Resident to Resident Altercation (Aggressor/Victim) updated on 1/30/18, documented Resident #6 was the victim in a resident-to-resident altercation on 12/31/17. Another resident wandered in her room and when she called for help to get the resident out, yet another resident entered the room. Resident #6's yelling in urgency, overwhelmed the other resident and he began hitting her. The I&A dated 7/18/18 at 5:06 PM, documented Resident #6 was found on the floor next to the TV in the recreation/dining area. The resident reported pain in the right hip. An x-ray was ordered and a [MEDICAL CONDITION] was confirmed. The Resident Statement of I&A dated 7/18/18, documented the resident stated she fell out of her chair and her head and hip were hurting. Resident #6 stated she was pushed out of her chair. A Nursing Progress Note dated 7/18/18 at 9:02 PM, documented the Nursing Supervisor was called because Resident #6 was found on the floor in the common area at 5:09 PM, holding her right hip. The physician (MD) and an RN assessed the resident, and an X-ray was taken and showed a right [MEDICAL CONDITION]. Resident #6 was sent to the hospital. The facility Investigation Form dated 7/20/18 for the incident dated 7/18/18 at 4:53 PM, documented Resident #6 was found on the floor in the common area and complained of right leg pain. An X-ray revealed a [MEDICAL CONDITION]. No staff witnesses were present. Several residents were seated in the common area. Review of video camera footage revealed an altercation between Residents #8 and #6. Resident #8 pulled Resident #6 up from her chair by her wrists, they both walked holding onto each other, Resident #6 pulled away, lost her balance and fell to the floor. Resident #8 lost his balance and fell on Resident #6's feet, and then rolls off the resident. A Hospital Internal Medicine Progress Note dated 7/20/18, documented the patient was admitted on [DATE]. The patient was brought in by Emergency Medical Services (EMS) secondary to a fall. The Family expressed concerns about abuse by another resident at the facility, including their impression the patient may not have fallen as she may have been pushed. The patient had a closed right [MEDICAL CONDITION] that was treated with surgery. The CCP Resident to Resident Altercation (Aggressor/Victim) updated on 1/30/18, documented an IDT review of the incident on 7/18/18. Resident #6 was involved in a resident-to-resident altercation. Another resident open handedly slapped Resident #6 on her right cheek. The other resident then lifted Resident #6 from her wheelchair by her left arm. Both residents moved around, and when the other resident lost grip on Resident #6's arm, Resident #6 fell down to the floor. The fall caused a fractured femur head ([MEDICAL CONDITION]). During an interview on 10/1/18 at 2:43 PM, Director of Nursing (DON) stated the incident on 7/18/18 was not observed by staff. There was no supervision of Resident #8 at the time of the incident on 7/18/18. There was nothing formal in place for monitoring the residents. After the incident, they created a daily assignment sheet that included dining room and front hall monitoring from 2 PM - 6:30 PM when residents congregate in these areas, when there was no activity during that time period. One-to-one supervision for Resident #8 was started after the incident on 7/18/18. There was an incident with Resident #8 and another resident on 9/4/18. The incident occurred when there no assigned monitor. They had to review the video footage to see what happened. Since the incident on 9/4/18, Resident #8 has been on one-to-one supervision during all waking hours. During an interview on 11/5/18 at 9:24 AM, Certified Nursing Assistant (CNA #2) stated she was working on 7/18/18 but was not in charge of watching the resident. She was not familiar with Resident #8's history or behaviors. During an interview on 11/5/18 at 11:09 AM, CNA #1 stated she was very familiar with the resident. She was working the day Resident #6 was found on the floor, but she was on a scheduled break at the time of the incident. On the video, she saw Resident #8 slap a resident in the face, then Resident #8 slapped Resident #6 twice. Resident #6 was trying to swat Resident #8 off her. Resident #8 grabbed hold of her arm and pulled her of the wheelchair. Both residents fell . From what she could see on the video, there was no staff in the area. Resident #8 is very combative. The incident with Resident #6 was not his first incident with a resident. She was not sure if the resident was hurt. Resident #8's aggressive behaviors are out of the blue. He could be sitting there calm one minute, and the next, totally aggressive. It's very quick with him. That's the way it was on video. It was very fast. The resident was not on one-to-one supervision until Resident #6 broke her hip. During an interview on 11/6/18 at 9:35 AM, Housekeeper (HK #1) stated on the day of the incident (7/18/18) he was using his floor cleaning machine when a resident came over to him to get his attention. There was a resident on the floor in front of the TV, in one of the living room areas. The resident was in obvious distress. He did not recall staff being in the area at the time. He went to get someone from Nursing to help the resident. During an interview on 11/6/18 at 2:45 PM, Nurse Practitioner (NP #1) stated Resident #8 was unpredictable, and could be very calm, pleasant, and cooperative and then suddenly the opposite. She watched video of the incident on 7/18/18 and said it all happened rather quickly. She said Resident #8 should not have been left unattended where other residents were gathered. Resident #8 had been on one-to-one supervision for quite a while. Resident #6 was not the only resident that Resident #8 has had altercations with. She said she has stepped in when a resident was being approached by Resident #8. During an interview on 11/6/18 at 3:46 PM, SW #1 stated Resident #8 was not able to have a cohesive conversation and had a frustration of not being able to help someone, and not being able to understand why he could not. During an interview on 11/7/18 at 1:17 PM, MD #1 stated he was not aware of the resident-to-resident incident between Residents #8 and #6 on 12/31/17. On 7/18/18, he was called and was told the resident had fallen. He saw the resident, the hip looked broken, and he ordered an x-ray. He didn't ask Resident #6 how it happened because he was more concerned about the fracture. The facility discovered how it happened by watching the video tape after another resident told them that Resident #8 lifted Resident #6 up out of the wheelchair and then she fell on the floor. He was not aware that the fall was the result of a resident-to-resident altercation, and did not find out about the video, until a week after the incident. He said Resident #8 was unpredictable and did not pick a fight with everyone. It was out of the blue. Resident #8's behaviors are very difficult to treat effectively because he could be perfectly pleasant, shake the doctor's hand, and had no aggressive behaviors, and then he had totally unpredictable aggressive behaviors. Resident #8 should not be left unattended with residents because he was so unpredictable. He would expect the team to come up with interventions to keep all residents safe. During an interview on 11/15/18 at 9:43 AM, Medical Director (MD#2) stated that after speaking with the Administrator, there was no staff in the area during the time of the incident on 7/18/18. MD #2 said there was lack of supervision in an area that should have been supervised. When there were residents in the area, there needed to be supervision. 10 NYCRR 415.12(h)(1)

Plan of Correction: ApprovedDecember 28, 2018

Resident #8 was placed on 1:1 while awake. A beam alarm was applied to his bedroom door to detect when the resident leaves his room. Staff will resume 1:1 supervision when he leaves his room. A lounge monitoring program was initiated on the unit. An employee is assigned to directly observe residents in the lounge from 2:30 p.m. while residents are in this area.
All other residents could be affected by the deficient practice. Any resident deemed to have potential for aggression will be individually care planned to provide supervison and/or other interventions to prevent physical altercations.
DON or designee will review all Resident to Resident I&A?s in the past 3 months to verify that adequate supervision was provided for each instance.
All nursing staff will attend education regarding the lounge monitoring program.
All nursing staff will attend education on Dementia and Behavioral Management.
Unit manager will audit the monitoring documentation weekly for one month, then bi-weekly for two months, then as determined by QA committee.
Responsible: Director of Nursing

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: January 10, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case# NY 082), the facility did not ensure residents had the right to self-determination and access to services outside of the facility, for one resident (Resident #9) of ten residents reviewed. Specifically, Resident #9 complained to staff of severe hip and leg pain on 9/1/18 and requested to go to the hospital. However, the resident was not sent to the hospital until the resident's family called 911 at 5:50 PM on 9/2/18 after the resident continued to request to be sent to the hospital for severe pain in the hip and leg. This is evidenced by: Resident #9 The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Notification of a Change in a Resident's Condition revised 12/2016, documented the nurse was to notify the resident's Attending Physician or physician when there was a significant change in the resident's physical/emotional/mental condition. The P&P titled Pain Assessment and Management revised 3/2015, documented significant changes in a resident's pain level were to be reported to the physician or practitioner. The Care Plan Activity Report for Pain initiated 8/7/17, documented the potential for alteration in comfort/pain related to a history of [MEDICAL CONDITION] arthritis and chronic pain. The resident was able to make needs known and was able to communicate what works well for management of pain. The goal for the care plan was the resident would have pain controlled with no increase in pain level through the next review. As an intervention, staff were to encourage the resident to report occurrences of pain at onset. Review of the Progress Notes for 9/1/18, documented no notes about the resident's condition. A Nursing Progress Note dated 9/2/18 at 5:53 PM written by Registered Nurse Supervisor (RNS #1), documented a late entry for 9/1/18 (untimed). RNS #1 was called by the LPN. The LPN reported the resident continued to have pain in her left hip and leg. A Nursing Progress Note dated 9/2/18 at 1:23 AM, documented the resident was in her recliner rubbing her leg and complaining of severe pain. The on-call NP (nurse practitioner) was called and ordered that the resident receive [MEDICATION NAME] (narcotic pain medication). Review of the 24-Hour Supervisor Report dated 9/1/18 for all 3 shifts, documented no notes about the resident's condition. A Nursing Progress Note dated 9/2/18 at 6:44 PM written by RNS #1, documented the resident complained of severe pain in left hip and leg during the afternoon. Routine Tylenol was given as ordered with little effect. The resident called her son several times and told him she wanted to go to the hospital. The assessment of right hip and leg unchanged from yesterday. A call was placed to the Medical Director to obtain an x-ray order and to request stronger pain relief. While awaiting a return call, the resident's son called an ambulance and had the resident transferred to the hospital ED (emergency department). Review of the 24-Hour Supervisor Report dated 9/2/18 (3PM-11PM) documented, the resident complained of right hip and leg pain. The resident's son called an ambulance and had the resident transferred to the ER. The EMS (emergency medical services) Pre-hospital Care report (PCR) dated 9/2/18, documented an ambulance was dispatched at 5:52 PM and arrived at the resident at 6:04 PM. The resident was asleep in her recliner. The facility did not call 911 as they did not feel she needed to be evaluated. Per the resident's son, the resident was in a lot of pain and he had never seen her like that before. When the resident woke up, she stated she had a lot of pain in her right hip that started yesterday. A Grievance Form for the date of occurrence 9/1/18 - 9/2/18, and dated 9/3/18, documented the social worker (SW) heard loud voices coming from the resident's room. The resident's daughter-in-law (DIL) told her the resident complained of pain in her leg on Saturday night (9/1/18) and told RN Supervisor (RNS) #1 she wanted to go to the hospital. RNS#1 spoke with the resident's son (HCP) and he requested the resident be sent to the ER. On Sunday morning (9/2/18) when the resident's son called the facility to follow-up, RNS #1 stated they did not send her because they have sent her before and there has been nothing wrong with her. The family was upset because RNS #1 made the determination on her own. The DIL stated a nursing assistant called the resident's son to see how the resident was doing and told him the resident had been stating she was in excruciating pain all day. The son had to come into the facility and call 911 himself. A Concern/Grievance - Resident Notification Summary for Resident #9 dated 9/13/18, documented the nurse would not send the resident to the ER when asked, and did not continue to reach out to the provider, administrator, Director of Nursing (DON), etc. The summary of actions taken were a performance correction notice and education. During an interview on 10/3/18 at 12:57 PM, Registered Nurse Manager (RNM #2) stated, anytime an alert and oriented resident wanted to go to the hospital, they should be sent. She stated she knew Resident #9 well enough, that if she hurts, she hurts. The resident was alert and oriented. There was always a MD or NP available, or Skype was available for a MD. Skype has been used in the facility and there has been education on it. There was an on-call list of providers and if the on-call MD did not return the call, she would go down the list until she reached someone. During a interview on 10/23/18 at 3:41 PM, RNS #1 stated the resident was having pain and wanted to go to the hospital on [DATE], but the resident had a history of [REDACTED]. In long term care facilities they did everything they could for the resident in the facility to avoid sending the resident to the hospital. RNS#1 stated the resident's son ended up calling 911 and the resident was sent to the hospital. During a interview on 10/25/18 at 1:52 PM, the DON stated, as soon as a resident asked to go to the hospital, the resident should have been sent. During a interview on 10/26/18 at 1:53 PM, the Social Worker (SW #1) stated she received the grievance on the Monday following the incident. The family said the resident was really upset because she was having pain over the weekend and wanted to go to the hospital. The resident's son wanted her to go to the hospital. The nurse called the doctor, but could not reach him. The nurse felt in her nursing judgment the resident did not need to go to the hospital. The nurse was talked to about this. The son did not realize that the resident did not go to the hospital on [DATE]. He wanted them to check her and then send her to the hospital. The resident was sent to the hospital the next day when the resident's son came in and called EMS. During a interview on 10/29/18 at 2:36 PM, LPN #1 stated the Certified Nursing Assistant (CNA) approached her and told her the resident was complaining of pain. She reported to RNS#1 that the resident was complaining that she was in pain, felt sick and wanted to go to the hospital. LPN #1 re-stated that she approached RNS #1 a few times about the resident and stressed that the resident was in pain and wanted to go to the hospital. 10 NYCRR 415.3(c)(1)(i)

Plan of Correction: ApprovedDecember 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #9 returned from the hospital on [DATE] with the pain medication [MEDICATION NAME] 5/325mg every 6 hours as needed for pain. Resident #9 was closely followed by medical providers and several diagnostic exams were performed in the facility. Resident had a [MEDICATION NAME] 25mcg patch added on 9/6/18 which was then decreased to a 12mcg patch on 10/2/18. Resident continues to be asked her pain level daily; has not requested her PRN [MEDICATION NAME] since 12/8/18
All other residents could be affected by the deficient practice.
All residents or their representatives will be contacted to verify that self-determination in accessing services outside the facility has been preserved.
All LPN?s and RN?s will attend education regarding use of Tele-med cart and Resident Rights.
All RN & LPN supervisors will be educated regarding 24hr supervisor report logging and reporting process.
DON will compare the 24hr supervisor report sheets against the 24hour progress note report 5 days/week verifying completion and accuracy.
Social Work will interview 10 Residents monthly x 3 months to verify that any medical concerns voiced were addressed timely and to their satisfaction.

Responsible: Director of Nursing