Samaritan Keep Nursing Home Inc
December 15, 2017 Complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not 475"

Scope: Isolated
Severity: Actual harm has occurred
Citation date: December 15, 2017
Corrected date: February 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the abbreviated survey (NY 585), it was determined for 6 of 8 residents reviewed for abuse (Residents #4, 5, 6, 7, 8, and 9), the facility did not ensure residents had the right to be free from abuse. Specifically, Resident #5 had multiple incidents of physical aggression towards other residents including Residents 6, 7, 8, and 9, and the facility did not ensure interventions were implemented to prevent abuse. The interventions in place to prevent abuse were not re-evaluated when Resident #5 continued to have incidents with other residents, resulting in Resident #5 entering Resident #4's room and injuring her. This resulted in actual harm to Resident #4 that is not immediate jeopardy. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition per the 5/4/2017 Minimum Data Set (MDS) was severely impaired. The 4/20/2017 social worker #14's progress note documented the resident was at the facility from 4/11/2017 to 4/13/2017, and his spouse took him home. She was not able to manage him at home so he returned to the facility on [DATE] for long term care. Nursing progress notes documented: - on 4/21/2017, the resident was anxious, agitated, verbally aggressive, and slammed doors on the unit. He was not re-directable and was very aggressive getting into other resident's faces. - On 4/22/2017, the resident was aggressive with 2 residents and verbally aggressive with a certified nurse aide (CNA), and an order was obtained for as needed [MEDICATION NAME] (sedative). The 4/23/2017 admission history and physical documented the resident had behaviors that the family was unable to manage at home related to dementia and a head injury 6 weeks ago. The resident received [MEDICATION NAME] (anti-psychotic medication) and that was to continue. Incident reports documented on 4/25/2017, the resident slapped Resident #7 on the right arm and on 4/26/2017, the resident slapped his roommate's arm (Resident #8) to wake him up as he thought Resident #8 was in his bed. The 4/27/2017 nursing progress note documented the resident was aggressive, constantly wandering from room to room, and was very easily agitated. The comprehensive care plan (CCP), initiated on 4/28/2017, documented the resident wandered into other residents' rooms and was inappropriate with them. The plan included 15 minute checks, redirect, and to provide 1:1 when the behavior occurred. The 5/2/2017 at 3:40 PM, LPN's progress note documented the resident was arguing with a male resident and threatened him. The 5/3/2017 incident report documented Resident #9 was found on the floor outside of her room and upon review of the video camera footage, it was determined Resident #5 pushed Resident #9 down. After the incident, Resident #5 stated he thought Resident #9 was in his room and he wanted her to leave. The 5/4/2017 at 12:26 AM, LPN #7's progress note documented the resident was found in another resident's room and staff needed to monitor his whereabouts. On 5/4/2017, the CCP was revised and documented the resident had behaviors. The plan included assessing causes of the resident's wandering; allowing the resident to express his feelings; checking the resident's whereabouts every 30 minutes, and to use a door alarm. On 5/4/2017, RN Manager #6 added to the 4/25, 4/26, and 5/3/2017 incident reports that the plan to prevent further incidents included moving the resident to a private room and placing him on 15 minute checks. The CCP was not updated to reflect the change from 30 minute to 15 minute checks. The 5/5/2017 nursing progress note documented the resident was yelling at staff and a resident and raised his fist to punch a CNA. Incident reports documented: - On 5/6/2017 at 8:30 PM, Residents #5 and 6 were in a room screaming at one another; Resident #6 stated she was beaten up, and Resident #6's clavicle was red. - On 5/6/2017 at 10 PM, Resident #5 wandered out of his room, was not re-directable, and tried to enter another resident's room. CNA #8 tried to intervene and the resident punched her full force in the jaw. The 5/7/2017 LPN #10's progress note documented beginning at 11 AM that day, the resident was placed on 1:1 per the Administrator. The resident needed constant redirection, had angry outbursts, and was to be given plastic utensils as he threatened to stab others. Nursing progress notes documented: - On 5/8/2017, RN Manager #6 noted the resident became the most upset when he wandered into other residents' rooms and thought those residents were in his room. The resident was on 1:1 at that time. - On 5/9/2017, the resident threatened to beat up the nurse. - On 5/10/2017 at 3:15 AM, the resident was found in another resident's room standing in the doorway. There was no further explanation of this event or documentation of whether he remained on 1:1. - On 5/11/2017, LPN #7 documented at 4:57 AM, the resident was on 15 minute checks with a door alarm on the night shift and was found in the hallway twice that shift. - On 5/11/2017 2:05 PM, RN Manager #6 documented the resident was on 1:1 while awake and 15 minute checks at night with a door alarm. The nursing progress notes contained no explanation as to how the decision was made to discontinue 1:1 for the resident at night. - On 5/15/2017 at 2:44 PM, LPN #11 documented at 2:44 PM, the resident had an altercation with another resident over the weekend and the physician was updated. There was no further information in the medical record about the altercation and when asked for an incident report, the facility was unable to provide one. - On 5/16/2017, LPN #11 documented the resident had an increase in physically aggressive behaviors. - On 5/17/2017 at 2:24 AM, LPN #7 documented the resident's door alarm was not turned on and she found him in the hallway. The resident said a lady was in his bed and if anyone was in his room he would throw them out. LPN #7 documented there was no one in the resident's room at that time and she turned his door alarm on. The 5/2017 Medication Administration Record [REDACTED]. The 5/19/2017 social worker #14's progress note documented the resident had a a 1:1 sitter 24 hours per day as he had agitation and struck out at residents and staff (The social worker's documentation of the resident's plan was not consistent with RN Manager #6 who documented 1:1 was discontinued at night on 5/11/2017). The mood and behavior report documented on 5/20/2017 at 1:34 AM, the resident exhibited behaviors of cursing, hitting, slapping, shaking his fist at others, insulting others, interrupting others, teasing, threatening, verbal and physical aggression, yelling, hitting, grabbing, and persistent anger. The 5/20/2017 incident report documented at 1:40 AM, Resident #4 was found on the floor in her room bleeding from her head. Resident #4 sustained a hematoma to the right temple with bruising to the jawline, shoulder, elbow, and knee. The DON at the time of the incident, documented after watching the video camera footage, the facility determined that Resident #5 entered Resident #4's room prior to her being found on the floor; Resident #5 had behaviors and had been on 15 minute checks that were increased to 1:1 monitoring. Resident #5 was not on 1:1 at the time of the incident, and Resident #5 was out of his room for 6 minutes with no staff responding to his door alarm. Resident #5 was placed back on 1:1 after the incident and staff were reminded to respond to his alarm immediately and to ensure staff cover for one another if breaks were taken. The investigation included statements from 2 staff members working on the unit on 5/20/2017 and the RN Supervisor including: - LPN #12's statement documented she was off the unit at break when the incident occurred but prior to the incident, the resident was aggressive towards CNA #16 so she tried to give him [MEDICATION NAME] without success. She called the Supervisor who got the resident to take the [MEDICATION NAME]. (The resident's 5/2017 MAR indicated [REDACTED]. - CNA #13's statement documented she heard the resident's door alarm sounding when she was in another resident's room. The investigation did not include a statement from CNA #16, who was also working at the time of the incident. - RN Supervisor #18's statement was dated 5/25/2017 and documented when she got to the unit on 5/20/2017, Resident #4 was on the floor, she was not aware Resident #5 had been in the room, and she assessed Resident #4 for a fall from bed and sent her to the hospital. She documented she was not aware Resident #5 was involved in the incident until the next day when someone reviewed the video camera footage and told her. The 5/20/2017 nursing progress note for Resident #4 documented she had bruises to the right side of the face, right shoulder, right knee, and an open area to the right forehead. The 5/20/2017 LPN #10's progress notes documented at 9:30 AM, the resident was yelling at the safety aide and threatening to harm anyone and at 2 PM, he was physically aggressive with safety aide. RN Manager #6's progress note dated 5/23/2017 at 10:03 AM, documented the resident was on 1:1 and that was discontinued at night on 5/16/2017 as medications were increased that day. After 5/16/2017, he remained on 1:1 during the day and 15 minute checks at night with a door alarm. After his agitated episode on the night of 5/19/2017 into the morning of 5/20/2017, he was placed back on 1:1 (This note was inconsistent with her note written on 5/11/2017 when she documented 1:1 at night was discontinued on that date). On 11/3/2017, the surveyor requested from the facility in writing any documentation related to 15 minute checks or 1:1 monitoring done for the resident from admission to present and on 11/6/2017, the facility provided the surveyor with copies of forms used to document 15 minute checks on the resident. No documentation of 1:1 monitoring was provided by the facility. On 11/30/2017 at 12:26 PM, CNA #15 stated in an interview: - in 4/2017 and 5/2017, the resident had behaviors including waking into other residents' rooms, being very aggressive, yelling at other residents to get out of his bed, and he did not do well with redirection. - The resident would get up in the middle of the night, approach staff, and punch or hit them for no reason. - One night, she followed the resident into another resident's room and he slammed the door in her face. She opened the door and followed him into the room because she was scared he would hurt the other resident who was bedbound. She stated this was before they believed that he pulled Resident #4 out of her bed. - The night they thought the resident pulled Resident #4 out of her bed, he was not on 1:1 and she did not know why. She would find out at the beginning of the shift if the resident was on 1:1 as it would be written on the communication board. She thought the decision to take him off 1:1 was made by the Unit Manager. - CNA #15 stated when the resident was on 1:1 they also referred to that as door duty and that meant someone needed to sit outside his door the entire shift and monitor his whereabouts. - When the resident was given a door alarm, it agitated him more. He did not like the alarm sound and the staff did not want to set the alarm off at night because if it woke the resident up, it would trigger more behaviors. She stated the staff would walk on the opposite side of the hall from the resident's room and would not go in his room on the night shift so they did not set the alarm off. On 11/30/2017 at 1:27 PM, CNA #17 stated in an interview, on 5/6/2017, she heard Resident #6 yelling and when she got to her, Resident #5 was touching Resident #6's neck, Resident #6's neck was red, and Resident #6 said Resident #5 was beating her up. She stated it took herself and the safety aide to physically remove Resident #5 from the area of Resident #6. CNA #17 stated Resident #5 pulled Resident #4 out of bed and during that time period, Resident #5 thought every room was his and he wandered from room to room and yelled at residents to get out of his room. She stated she did 1:1 with the resident a few times and when she did, she was supposed to sit outside his room and monitor the door and then stay with him if he left his room. She stated this was difficult because his behavior was scary and there were times that she ran from him when he chased her because he would punch, kick, and hit for no reason. On 12/1/2017 at 12:31 PM, LPN #7 stated in an interview, in 4/2017 and 5/2017, the resident would turn violent very quickly. At times he was on 1:1 on the night shift and at other times he was not. LPN #7 stated in 5/2017 on the night shift, the resident would wander from room to room and yell at the residents in those rooms that they were in his room. She stated there were times when she found him in other residents' rooms and he would be mad because he thought those residents were in his room. She stated there were also times when she she found his door alarm turned off. She stated the staff would turn it off and go into the room and then forget to turn it back on when they left. She stated the staff did this because they did not want the alarm to sound when they entered as they did not want to wake the resident up. On 12/4/2017 at 12:50 PM, CNA #16 stated in an interview, she was working when the facility believed that Resident #5 pulled Resident #4 out of her bed. She stated herself and CNA #13 were doing second rounds at around 1 AM and saw Resident #5 in the hall. She stated they were told if the resident was up, they needed to watch him so CNA #13 approached him and he charged her. She also tried to approach him and he charged her too so they told LPN #12. She thought LPN #12 and the Supervisor medicated the resident but her and CNA #13 went back to taking care of other residents when the nurses responded so she did not know for sure. She stated at around 1:20 AM, herself and CNA #13 found Resident #4 on the floor, lying face down, and bleeding from either her head or nose. She stated when they found Resident #4, Resident #5 was already back in his room so she did not know Resident #5 as in Resident #4's room until someone reviewed the video camera footage and she did not think the resident had a door alarm at the time of the incident. She stated there were times the resident was on 1:1 and the purpose of the 1:1 was for someone to stay with him at all times and make sure he did not go into any other residents' rooms. On 12/6/2017 at 9:12 AM, during a telephone conversation with the DON, the surveyor requested the facility's policy on 1:1 monitoring. The DON stated she did not know if the facility had a policy for 1:1 monitoring and stated she would find out. On 12/7/2017 at 11:10 AM, the Administrator's Administrative Assistant sent an email to the surveyor which documented she was sending the requested information including the policies that the facility had. A policy for 1:1 monitoring was not included. On 12/7/2017 at 11 AM, RN Manager #6 stated in an interview: - when the resident was admitted to the facility in 4/2017, he was very behavioral. One minute he would swing at staff, yell, and threaten, and the next minute, he would apologize. - In 5/2017, the resident's aggression increased and at the end of 5/2017, he went to the hospital for about a month and had his medications adjusted. - The resident was on 1:1 in 4/2017, was taken off 1:1 in 5/2017, and went back on 1:1 after he went into Resident #4's room and they thought he pulled her out of bed. - Resident #4 could not move on her own, roll over, or fall out of bed on her own, so they determined when Resident #5 was in her room, he must have pulled her out of bed. - She was not aware of any other times Resident #5 went into other residents' rooms and threatened them or thought they were in his room. - When the resident was taken off 1:1 at night on 5/11/2017, the decision was made by the behavioral team and she was part of that team. She stated documentation of the team meeting was her 5/11/2017 nursing progress note and there was no further documentation. She stated she did not remember the discussion surrounding the decision to discontinue the resident's 1:1 at night. - She did not know why the night shift nurse documented in the early morning of 5/11/2017, that 1:1 at night was discontinued. She stated that note was written before the behavioral team met and may have been due to lack of staff to provide 1:1 that shift. - She did not know why she documented in a progress note on 5/23/2017 that 1:1 at night was discontinued on 5/16/2017 when it was discontinued on 5/11/2017 by the behavioral team. - The behavioral team met on Thursdays and would have reviewed the resident's plan and incidents from 5/12/2017 to 5/17/2017 at the 5/18/2017 meeting. She did not know if there were any changes to the resident's plan of care at that time. - She never heard any reports of staff finding Resident #5's door alarm turned off but was aware of another issue with the alarm. She stated the alarm the resident had sounded once, and did not continue to sound until someone responded to it. She stated they determined this was an issue, and before the resident returned to the facility from the hospital in 6/2017, they replaced his alarm with one that that sounded continuously until someone responded to it. On 12/12/2017 at 1:05 PM, the attending physician stated in an interview, Resident #5 was admitted to the facility from the hospital, went home for a few days, and when his spouse could not manage him at home, he was returned to the facility. He was aware of the resident's behaviors at the time of admission and the behaviors included agitation, aggression, and wandering. The physician stated the resident's behaviors were challenging because one minute he was pleasant and the next minute, he was very aggressive. He stated he had only witnessed the resident in a pleasant state but received reports from the staff about the resident's behaviors and aggression. He stated the facility set standards for supervising residents and would implement those standards based on incidents. He stated he did not write orders for 1:1 or to discontinue 1:1 and would be updated after those changes were made. He stated he was not part of the facility's behavioral team but would be updated after the meetings with any areas of concern. He stated he was notified Resident #4 went to the emergency roiagnom on [DATE] and he saw her 5 days after the incident and she had a head contusion, abrasion on her head, and multiple bruises. He stated Resident #4 could not remember the incident and when he saw her 5 days after, the investigation was still in progress and he did not know what happened. He did not believe that Resident #4 could roll or fall out of bed on her own but he was not notified when the facility investigation was completed and did not know the outcome. He stated after the incident on 5/20/2017, he had the psychiatrist see Resident #4 a few times and later on, he was transferred to the hospital and was there for about a month. On 12/15/2017 at 11:25 AM, social worker #14 stated in an interview, he did know where he got the information from when he wrote the 5/19/2017 progress note. He stated if he wrote a note documenting the resident was on 1:1 then that was his understanding and he could have gotten the information from the behavioral team, morning report, or from the unit staff. He stated he did not recall any specifics about the resident's plan for 1:1 and could not say whether the resident was on 1:1 when the incident occurred with Resident #4 on 5/20/2017 or whether the incident prompted the resident to be placed back on 1:1. 10NYCRR 415.4(b)

Plan of Correction: ApprovedJanuary 29, 2018

1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?
Resident # 5
The resident?s behaviors have resolved. The resident continues to have a private room. His medical condition has declined due to natural processes. Resident no longer displays increased behaviors that affect others. Resident no longer ambulates independently. Resident is monitored for any increasing behaviors; any incidence of increasing behaviors will be reported to nursing and medical staff. There have been no reports of increased behaviors by resident#5.
Resident # 4:
Resident no longer resides here.
Resident # 9: is not at risk for abuse because resident #5 no longer enters other resident?s rooms. He is always assisted when he ambulates in the hallway.

Resident # 6: is not at risk for abuse by resident #5 because Resident #6 was relocated to a unit with other residents that she was familiar with. She did not need a secure unit as she is oriented and not at risk for elopement.
Resident # 7 continues to ambulate with support from staff members and supervision for safety as she continues to reach out to other residents to touch them when they are also ambulating in the hallways. Resdient#5 is now unable to ambulate independently and is always escorted by a staff member. Resident # 7 is longer at risk for abuse by resident #5.
Resident # 8:
Resident #5 no longer resides in resident?s #8?s room. He has a private room. There have not been any further issues involving resident #8. Resident # 8 is longer at risk for abuse by resident #5.
2. How you will identify other residents having the potential affected by the same deficient practice and what corrective action will be taken.
? A Casper Report and Comprehensive Behavioral Care Plan review of all residents? have been completed to identify any other residents with behavioral issues. Any residents identified to have any behavioral issues has been addressed by conducting a behavioral team meeting to ensure all needs are being met. All Comprehensive Care plans have been reviewed and updated as appropriate. All residents identified will be monitored for effectiveness of any new intervention with complete and thorough documentation.
3. What measure will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
? A Behavioral Health Policy will be developed to include: All residents that are newly admitted with any behavioral issues will be assessed by the interdisciplinary team and an individualized Comprehensive Care plan will be initiated and implemented. In the event that behavior is not decreased by interventions, the physician will be contacted for further recommendations.
? Any resident that demonstrates increasing behaviors that are not being met by interventions associated with the individualized Comprehensive Care plan will have a Behavioral Root Cause Analysis which will include an interdisciplinary team approach including the Medical provider, Nursing, Social Work, Pharmacy, Recreational Activities and family or care giver member as appropriate. A follow up meeting will occur to review interventions and effectiveness or revision of Care Plan by the behavioral team.
? A Safety Visual Observation policy was reviewed and revised.
? A Recreational Activities individualized evaluation will be completed with a plan of daily activities that will be implemented.
? Activities Independent Tool Kit will be developed and placed on unit for resident needs to assist care givers to promote positive stimulation, redirection and healthy well-being.
? All residents identified to have increasing behavioral issues will be discussed in morning meeting on a daily basis to identify potential interventions and to monitor effectiveness.
? Education will be completed for all staff to revised policies.
? Education will be completed to all direct care providers on Behavioral strategies for the Dementia resident
4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Nursing or designee will conduct the following audits:
? An audit of 100% of Residents that trigger for behaviors will be completed each month to ensure that all residents who have a Behavioral Comprehensive Care plan to ensure that all interventions are implemented appropriately and effective
? An audit for 100% all residents that are identified with conditions that demonstrate increasing behaviors that affect self or others to ensure that all residents have individualized interventions that promote positive behaviors.
? Each individual audit will be completed monthly until 100% compliance has been achieved for 3 consecutive months. Monitoring for compliance is the responsibility of the Director of Nursing and will be reported to the Quality Improvement Council.
5. The Director of Nursing will be responsible for this deficiency
Completion date: (MONTH) 13th, (YEAR)
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REVISED PLAN OF CORRECTION
1.29.18
1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?
Q1: Please note Resident #4's discharge date and if changes had been made to the plan prior to discharge.
A1: 01/01/2018 There were no changes to resident 4 Care Plan.
Q2: Please clarify if sentence noting Resident #9 is talking about Resident #9 or #5 now being assisted with ambulation.
A2: Resident #5 is now being assisted with all ambulation
Q3: Does not identify if Resident #9 has the potential to be a victim of abuse by others and if a plan was implemented.
A3: Resident #5 entered the room of resident #9. Resident #9 stays in her room except for meals and activities in the dining area. She is able to make her needs known. She does not display any characteristics that would cause others to target her. Resident #9 has been Care Planned for potential risk of abuse from others.
Q4: Does not include if a plan was implemented for Resident #7 to ensure she was not a potential victim of abuse, given her reaching out to others while ambulating.
A4: The Care Plan for resident #7 was updated to include educating staff about respecting personal space of others while ambulating. Staff have been educated on principles of ambulating resident #7, Care Plan includes providing the resident with books, and personal items to help her stay focused on the items and not to reach out to other residents.
Q5: Please clarify - documents resident has a private room under correction for Resident #8 - does this mean Resident #8 or #5 has a private room?
A5: Resident #5 was moved to a private room closer to the Nurse?s Station to allow increased visual observation by staff. A door alarm was placed on resident #5?s room alerting all staff when resident #5 chooses to leave his room to ambulate. A staff member immediately escorts him for his ambulation around the Unit.
Q6: Does not identify if Resident #8 has the potential to be a victim by other residents.
A6: Resident #5 was the roommate of resident #8. Resident #8 went into resident #5's bed by mistake. Resident #5 was moved to a private room. Resident #8 only leaves his room for meals. Resident #8 does not display any characteristics of intrusion or aggression towards others.
Q7: Does not include a plan on how the facility was to ensure the resident's involved in interactions with Resident #5 did not have negative outcomes based on the events or if a plan was implemented to monitor their potential psychosocial effects or the potential to be a victim by other residents and how the facility will ensure their safety and mental stability. This would also include a plan to maintain Resident #5's safety now that his condition has declined.
A7: After each resident to resident related incident, both residents are assessed to make sure that no ill effects have occurred. A plan was not implemented to monitor as we believe there were no ill effects following the resident to resident interactions as was documented in the Medical Record.
Following a resident to resident incident, a RN assessment is immediately completed for physical and psychological effects, social work also assesses the resident for any changes, and if the resident does not remember the interactions, staff are interviewed to include any changes in the resident behaviors, normal day to day activities of daily living.
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REVISED PLAN OF CORRECTION
1.29.18
2. Does not indicate how the facility will act to protect residents in similar situations.
Q1: Plan identifies residents with potential behaviors; plan does not address residents that have the potential to be a victim of abuse by residents with behaviors. Please include information on how the facility is addressing vulnerable residents. Does not identify who will be conducting/monitoring the new changes to interventions and their effectiveness.
A1: The Behavior Team Review Policy addresses the action to be taken immediately following any resident to resident interaction. This policy includes all interventions to be implemented by staff based upon the characteristics or triggers displayed by the resident.
A risk indicator for physically aggressive behavior will be completed.
For more complex or repeated behavioral situations, a Behavioral Root Cause Analysis will be completed and the residents? Individualized Comprehensive Care Plan will be updated to address and identify any resident who may demonstrate aggression toward others. This will decrease risks for future possible victims. The Interdisciplinary Behavior Team follows all residents with current behaviors.
The Director of Nursing will be responsible to ensure these audits are completed, and reported to the Quality Improvement Council x3 months until 100% compliance is achieved.
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REVISED PLAN OF CORRECTION
1.29.18
3. Does not include the measures the facility will take or the systems it will alter to ensure that the problem does not recur.
Q1: Does not identify if activity staff will be educated on new plan (P(NAME) notes education would be provided to all staff regarding revised policies - activities plan not identified as a policy).
A1: Activities continues to be part of the behavior team meetings and will implement any individualized strategies identified by the behavioral team for each resident.
Q2: Please clarify how the inconsistent documentation of safety checks and 1:1 are being addressed by the facility.
A2: The Safety Check form will be updated to include individualize interventions and an audit will be completed to be verify that all Safety checks for 1:1 observations have been completed x3 months and will be reported to Quality Improvement Council until 100% compliance has been achieved.

Q3: Plan addresses how CCP will be reviewed and revised, and does not include how staff are to respond in immediate instances that could affect the health and safety of other residents.
A3: All LPNs, CNA?s will be educated on behavioral interventions as part of the behavior team review policy.
Q4: Does not address how the facility will address the resident's lack of 1:1 when the resident was noted to be awake with behavioral symptoms during the 11 PM - 7 AM shift.
A4: There was a knowledge deficit with staff members based on poor communication and residents? sleep habits.
Q5: Does not address how the facility will ensure this does not recur for residents in similar situations.
A5: Communication with the Nurse Managers and Supervisors will ensure that 1:1 observations are completed as required.