Masonic Care Community of New York
September 15, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2016
Corrected date: November 14, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 5 residents (Resident #1) reviewed for [MEDICAL CONDITION] medications, the facility did not ensure the resident's drug regimen was free from unnecessary medications. Specifically, Resident #1 was administered anti-anxiety medications without consistent documentation of symptoms and [DIAGNOSES REDACTED]. In addition, when Resident #1's anti-anxiety medication was administered simultaneously with pain medication, there was no documented assessment whether the resident's symptoms were related to pain, anxiety, or both. Findings include: Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A 6/28/2016 comprehensive care plan (CCP) documented the resident had the potential for adjustment difficulties related to change in living condition. Staff were to reorient the resident to the facility, living areas, and identify themselves and their roles. The CCP had no documentation regarding anxiety, mood, use of [MEDICAL CONDITION] medications, or individualized interventions to address mood and/or behavioral symptoms. A 6/30/2016 physician order [REDACTED]. A 7/1/2016 physician progress notes [REDACTED]. He was administered a couple doses of [MEDICATION NAME] first and then [MEDICATION NAME]. The resident seemed to calm after the [MEDICATION NAME]. The resident had a possible [MEDICAL CONDITION] ([MEDICAL CONDITION], stroke) or TIA ([MEDICAL CONDITION], stroke). Family stated the resident had a history of [REDACTED]. Family requested the resident be provided with prn [MEDICATION NAME] and [MEDICATION NAME]. A 7/1/2016 physician order [REDACTED]. The medication administration record (MAR) documented the resident received prn [MEDICATION NAME] 15 times from 7/1 - 7/6/2016. Eleven of those 15 times prn [MEDICATION NAME] was administered simultaneously or within 6 minutes of the administration of [MEDICATION NAME]. There was no documentation on the MAR non-pharmacological interventions were attempted prior to [MEDICATION NAME] and [MEDICATION NAME] administration. Nursing progress notes between 7/1 - 7/6/2016 documented the resident received prn [MEDICATION NAME] for anxiety and/or prn [MEDICATION NAME] for symptoms including discomfort, restlessness and occasional pain. [MEDICATION NAME] was documented as administered 1 time, and [MEDICATION NAME] and [MEDICATION NAME] were documented to be administered 10 times simultaneously, or within 10 minutes of each other. There was no documentation in nursing progress notes of non-pharmacological interventions attempted prior to the administration of these 2 medications. A 7/6/2016 nursing progress notes documented a new order was in place for 10 mg of [MEDICATION NAME] every 2 hours prn. The [MEDICATION NAME] was administered at 8:07 PM, [MEDICATION NAME] at 9:50 PM, [MEDICATION NAME] at 10:19 PM, [MEDICATION NAME] with [MEDICATION NAME] at 12:20 AM and 2:20 AM, and [MEDICATION NAME] at 4:00 AM. There was no documentation of non pharmacological interventions attempted prior to their administration. During that night, the family refused interventions 1 time and requested an alternative for the anti-anxiety medication. A 7/6/2016 at 12:15 AM nursing progress note documented the resident was started on an antibiotic for a urinary tract infection [MEDICAL CONDITION]. A 7/7/2016 physician order [REDACTED]. There were no parameters in physician orders [REDACTED]. A 7/8/2016 physician progress notes [REDACTED]. He had significant hallucinations, was fearful, and [MEDICATION NAME] was ordered and not taken. The physician noted the [MEDICATION NAME] order would remain in place if he became more anxious. A routine [MEDICATION NAME] could be trialed. A 7/11/2016 physician progress notes [REDACTED]. The 0.25 mg prn [MEDICATION NAME] would be continued. The MAR documented the resident received prn [MEDICATION NAME] 21 times between 7/7 - 7/25/2016. Two of those times [MEDICATION NAME] was administered simultaneously with prn [MEDICATION NAME]. There was no documentation of non-pharmacological interventions attempted prior to their administration on the MAR. Nursing progress notes between 7/7 - 7/31/2016 documented the resident received prn [MEDICATION NAME] for anxiety and/or prn [MEDICATION NAME] for symptoms including discomfort, anxiety, moving in bed, restlessness and occasional pain. There was no documentation of non pharmacological interventions attempted prior to their administration. On 7/17/2016, the resident was administered prn [MEDICATION NAME] at 11:50 PM, the resident had been pulling at his brief, he was found to be incontinent with reddened areas to his groin. There was no documentation the resident was attempted to be toileted or provided care to address his toileting needs before administering the [MEDICATION NAME]. The 8/2016 MAR documented the resident received prn [MEDICATION NAME] on 8/8/2016 at 12:41 AM. There was no reason/symptoms documented on the MAR and there was not a correlating nursing progress note. The resident was observed: - On 9/12/2016 at 12:25 PM seated in the dining room being assisted by staff; at 5:28 PM in his room being assisted with his meal by family; - On 9/13/2016 from 8:43 AM - 9:15 AM, seated quietly assisted by staff with his breakfast meal; At 9:35 AM seated by the television with a sensory object on his lap; At 10:14 AM seated in lounge area with the television on; At 11:00 AM laying in his bed; At 1:15 PM in television lounge area; At 1:35 PM being assisted to his room to lay down by staff; From 1:35 PM - 2:30 PM laying in bed with the television on; - On 9/14/2016 at 9:05 AM seated at breakfast table quietly with a nurse; and at 1:30 PM, laying in bed quietly. During an interview with case manager #7 on 9/15/2016 at 10:19 AM, she stated the family was very involved in the resident's plan of care and at times directed care with staff. She stated sensory stimulation had been attempted with the resident, and that had been brought to the unit approximately 2 weeks prior to the survey. The case manager stated she did not have involvement in [MEDICAL CONDITION] medications or their addition to the resident's medication regime. She stated the resident was a nice man, she had heard he had some hallucinations identified by staff, and she had not heard of any other mood or behavioral concerns. She stated the resident's wife had not been in to visit in some time and the resident was now long term placement. During an interview with licensed practical nurse (LPN) #9 on 9/15/2016 at 10:50 AM, she stated the resident was very quiet. She stated the resident would occasionally fidget. She stated it was unclear if the resident had hallucinations as he would sometimes reach out and it seemed as if he was reaching for a blanket or his clothing. She stated she did not recall using any prn medications for the resident. She stated to administer the prn anxiety medication the resident would have to be displaying behaviors that were abnormal for him, such as jumping out of bed or feeling really anxious. She stated nurses were to document use of prn medications in the MAR and in nursing progress notes. LPN #9 stated non-pharmacological interventions should be attempted first including toileting, offering a drink, repositioning, or checking the resident environment. She stated these interventions should be documented in the nursing notes. She stated she may have administered [MEDICATION NAME] 1 times when the family reported the resident was restless. She stated prn medications should not be administered together or near a routine medication to determine if medications were effecting the resident. During an interview with physician #10 on 9/15/2016 at 11:00 AM, she stated the resident did have routine antipsychotic medications. She stated the resident had [MEDICATION NAME] in place for pain. She stated he did have knee pain and restlessness. She stated if the resident was voicing pain [MEDICATION NAME] should be administered. She stated nonpharmacological interventions should be attempted prior to administering any prn medications. She stated these interventions should be documented in the resident's medical record. She stated she knew the resident was provided with recent sensory stimulation. She stated the family had been involved in discussion of medications and wanted an anti-anxiety medication in place. She stated the resident's routine anti psychotic and routine anti anxiety had been steadily increased since 7/2016. Registered nurse (RN) #11 was contacted by phone on 9/15/2016 at 11:35 AM. RN #11 did not return the surveyors call prior to the exit of the recertification survey. During a telephone interview with RN #12 on 9/15/2016 at 11:41 AM, she stated the resident did not have behaviors. She stated he sometimes had anxiety symptoms and he had orders in place for routine and prn [MEDICATION NAME]. She stated the resident's anxiety symptoms would display as a lot of movement of his extremities. She stated she had provided the resident with prn medications. She stated it was not necessary to document why these medications were administered or what non pharmacological interventions were attempted prior to their administration as the resident was on comfort care and documentation was not necessary. Certified nurse aide (CNA)s #14, 15 and 16 were contacted by telephone on 9/15/2016 between 12:19 PM and 12:24 PM and were unavailable to interview prior to the exit of the recertification survey. During an interview with RN #18 on 9/15/2016 at 12:24 PM, she stated had administered prn medications to the resident for anxiety symptoms including trying to climb out of his bed. She stated the family would report the resident was having hallucinations. She stated she was unsure if she had administered both [MEDICATION NAME] and [MEDICATION NAME] together and she may have. She stated [MEDICATION NAME] was in place for pain. She stated prn medication use should have been recorded in the MAR. She stated non pharmacological interventions should have been attempted and it was not necessary to record interventions attempted. 10NYCRR415.12(l)(1)

Plan of Correction: ApprovedNovember 3, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
Resident #1: Clinical record reviewed by Director of Nursing and ADON/Quality Assurance Coordinator. Resident is no longer an active resident in the facility. Prior to discharge, the following individualized interventions regarding non-pharmacological measures were included as per plan of care for [MEDICAL CONDITION] drug use including soft lighting, music, massage. Although physician was highly involved in the medical care of the resident, including ongoing discussions pertaining to medical care and services with the resident and family, she was not notified of the frequency in which the resident was receiving prn medications and therefore did not make a formal re-evaluation of prn medication regime. Measures to ensure physician notification of residents receiving prn medications on a routine basis being implemented as reflected below.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
? All residents with physician orders [REDACTED]. Full house audit to identify all residents currently receiving prn pain medications, anti-anxiety and/or anti-psychotic medications to be completed and results to be provided to physician for review. Medication Administration policy & procedure to be updated to include physician notification of residents receiving prn medications on a routine basis. Consultant Pharmacist drug regime review process will continue to include ensuring indication for use, criteria for use and frequency of administration for prn medications with physician notification as appropriate.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
? Medication Administration policy and procedure to be revised to include physician notification of residents receiving prn medications on a routine basis.
? Existing and new licensed nursing staff to receive education on unnecessary medications, including need for implementation of non-pharmacological interventions prior to administration of prn medication and documentation requirements.
? Nursing Supervisory staff will be educated on the importance of ensuring an individualized care plan is in place identifying active diagnosis/symptoms as well as including individualized interventions to be attempted for symptom management.
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?
? Audit tool will be developed to monitor that non-pharmacological interventions were implemented prior to administration of prn pain and/or anti-anxiety medications as reflected in individualized care plan and ensure proper documentation requirements have been completed. This audit will be completed monthly for a total of 1 year to ensure 90-100% compliance. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assurance Committee on a monthly basis throughout the auditing period.
Responsible Person: Director of Nursing

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2016
Corrected date: November 14, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification and abbreviated surveys (#NY 903), it was determined for 1 of 30 sampled residents (Resident #6) and one additional resident (Resident #31), the facility did not provide an environment free of accident hazards or adequate supervision to prevent accidents. Specifically, the facility did not ensure the interdisciplinary team utilized accurate information when developing and evaluating the effectiveness of Residents' #6 and #31 care plan interventions for wandering behaviors. After Resident #6's first incident of exiting the building, there was no documentation her care plan interventions were reviewed for effectiveness; Resident #6 was able to wander outside the building again 2 months later. Additionally, it was unclear why the care plan team discontinued Resident #31's wanderguard and 15 minute checks, when the resident continued to wander and was then able to successfully exit the building with her walker, and wander near a vehicle and the security guard's shack. Findings include: 1) Resident #6 had [DIAGNOSES REDACTED]. The 1/29/2015 physician's orders [REDACTED]. The 10/26/2015 comprehensive care plan (CCP) documented the resident had dementia and was a high risk for elopement. The resident ambulated the Adirondack neighborhood (the resident's unit), the health pavilion and throughout the whole facility. Interventions included the resident be checked every 15-minutes, a wanderguard applied, and she was to be redirected to her household as she does seek to exit the building. The 3/30/2016 elopement risk screen documented the resident had dementia, was fully ambulatory, wandered aimlessly, was difficult to redirect and had no history of elopement attempts. The screen documented the resident was to be watched for elopement. Nursing progress notes dated 5/13/2016 at 9:24 PM documented the resident was seen by the front desk going out the door at 7:44 PM. A certified nurse aide (CNA), outside on her break, saw the resident, stayed with her and then she returned inside. The note documented the wanderguard system did not alarm when the resident went out the door and did alarm when she came back inside. On 5/29/2016 at 2:19 PM, nursing notes documented the resident wandered to the first floor 3 times that day, twice looking for her son, and another time wandered to the atrium to church. Nursing progress notes dated 5/30/2016 at 6:22 AM, documented the resident wandered the unit until 2 AM. The 6/16/2016 elopement risk screen documented the resident had no history of elopement or attempts and she was at a low risk of elopement. The rationale was unclear how this determination was made. The Minimum Data Set (MDS) assessment, dated 6/20/2016, documented the resident's cognition was severely impaired; she ambulated with supervision; and she wandered 4 to 6 days of this assessment period. Nursing progress notes documented the resident: - on 6/2/2016 at 12:31 PM, wandered to the lobby twice and returned on own; - on 6/19/2016 at 12:29 PM, frequently wandered on/off the household; - on 7/9/2016 at 12:33 PM, wandered twice to the first floor and was brought back without incident; - on 7/12/2016 at 7:17 AM, wandered the households all night; and - on 7/17/2016 at 5:01 PM, was seen by a CNA wandering through the parking garage doors as she parked her car. The wanderguard did not alarm upon re-entering the building and was replaced. The 7/17/2016 investigative report documented the resident was observed exiting the facility, was escorted back into the building by a CNA, and was last seen 15 minutes prior to exiting the building. The report documented the wanderguard system failed to alert. The resident's wanderguard was found to be working but was replaced as a precautionary measure. The facility's wanderguard system was checked and at times the alarm was not triggered. The report documented that 2 antennas were replaced. On 9/13/2016 at 2:40 PM, the surveyor observed the resident's bathroom door to be closed; the resident was not seen in her room. On 9/14/2016 at 8 AM, the resident's bedroom door was observed closed; the resident was not seated at her assigned place in the dining room for breakfast. On 9/14/2016 at approximately 12:30 PM, the Director of Nursing (DON) was asked to provide the incident report for the resident's wandering on 5/13/2016. At 1:35 PM, the Administrator stated the resident was seen exiting the building by front door staff, and because she was detected prior to exiting the building, an incident report was not completed. There was no documentation the resident's wandering incident on 5/13/2016 was investigated and no documentation the care plan was reviewed or updated to prevent recurrence. On 9/15/2016 at 12 PM, the DON stated in an interview that yesterday was the first time she heard the resident wandered out the front door back in (MONTH) (YEAR). She stated the Supervisor was the only one aware it occurred, and did not report it because the resident was within eyesight when she exited the building. The DON stated that according to the Supervisor's note, the resident's wanderguard did not alarm. There was no follow up to determine why it malfunctioned. She stated she did not consider the incident an elopement, but said it should had been investigated to determine why the wanderguard system failed. On 9/15/2016 at 1:05 PM, the Administrator stated in an interview that she learned yesterday the resident exited the building in (MONTH) (YEAR) and did not know what occurred at that time with the wanderguard system. She stated if she had she been aware, the incident would had been investigated. 2) Resident #31 had [DIAGNOSES REDACTED]. The 8/23/2015 and 11/10/2015 elopement risk screens documented the resident had dementia, was fully ambulatory, wandered aimlessly, voiced desires to leave, had no elopement attempts, and behavior her was redirected. The screen documented the resident was to be watched for elopement. Physician orders [REDACTED].#31. Nursing progress notes documented on 10/20/2015 at 2:40 AM, the resident found in kitchen area with butter knife hiding up her sleeve. She told staff she wanted to cut off her wanderguard. At 3:45 AM, a certified nurse aide (CNA) went to check the resident's wanderguard, and found it was missing from resident's ankle. The room was searched; the wanderguard, 3 spoons, 2 forks, and 2 butter knives were found in the resident's nightstand. On 10/21/2015 at 8:48 PM, nursing notes documented the resident cut or tore her wanderguard bracelet/band. Nursing notes dated 11/11/15 at 11:50 PM, documented the resident found in main hallway in an adjacent household. On 12/5/2015 at 8:04 AM, and 12/17/2015 at 2:45 AM, nursing notes documented the resident was up wandering the household, with unsuccessful attempts to redirect her to bed. On 1/19/2016 at 10:23 AM, the wanderguard use was reviewed by care plan team. Nursing notes documented the resident no longer wandered throughout the neighborhood; the resident voiced no desire to leave facility, ambulated on the unit and made no attempts at eloping. The team was in agreement to discontinue wanderguard and 15 minutes checks. The physician order [REDACTED]. Nursing progress notes dated 2/4/2016 at 6:09 AM documented the resident was wandering on the unit at the beginning of the shift. The 2/7/2016 elopement risk screen documented the resident had dementia, was fully ambulatory, wandered aimlessly, was content with placement, a history of elopement attempts were voiced with no action taken. The screen documented the resident was to be watched for elopement. The 2/8/2016 at 10:34 AM nursing progress note documented the resident was up all night wandering on the household. The 2/13/2016 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, and did not exhibit wandering behaviors during the assessment period. The rationale was unclear how this determination was made. The MDS specified the resident required extensive assistance of one for ambulating, and used a walker or wheelchair for mobility. The comprehensive care plan (CCP) dated on 2/22/2016, documented the resident was at high risk for elopement, had a history of [REDACTED]. had impaired memory and orientation. An incident investigation initiated on 2/28/2016 by registered nurse (RN) Manager #19 documented: - on 2/28/2016 at approximately 3:30 PM, the resident stated she wanted to go for a walk and walked to the security check point. - An interdisciplinary note entered by RN #19 on 2/28/2016 at 3:41 PM documented household staff were called by the receptionist and notified that a security guard brought the resident into the building. - The Investigation Summary signed by the Director of Nursing (DON) and dated 2/29/2016 documented she received a call from the RN Manager #19 informing her that Resident #31 exited the building and walked to the guard building. The DON documented the resident was known to walk around the household and had not made attempts to leave the building. On 9/14/2016 at 3:30 PM, during environmental/life safety document review of disaster drills, the surveyor observed a security officer's written statement that documented an incident involving Resident #31 that occurred on 2/28/2016 at approximately 3:30 PM. The officer's statement documented Resident #31 was observed outside near a vehicle with her walker. He was unsure if the person he was observing was a visitor or a resident. He met Resident #31 on the sidewalk near the gate before she was able to get on the street at the main entrance. The resident provided her name when asked, and stated I was just going for a walk to get some air. Will you walk with me my walking angels? The security officer returned to the guard shack, phoned the receptionist, and escorted Resident #31 back to the facility. RN Manager #19 was no longer employed by the facility and was not available for interview. On 9/15/2016 at 12:03 PM, the DON stated in an interview, she did not consider this elopement, as the resident went outside for a walk, was in view of staff, and did not have a plan to go anywhere. She also said the resident's cognitive status was taken into account on a case by case basis and the resident's severe cognitive impairment did not necessarily make her an elopement risk or require a wanderguard. On 9/15/2016 at 1:03 PM, the Administrator stated an elopement was when a confused resident left the building undetected, or did not return from leave of absence. She stated a lot of residents did not like the wanderguard. 10NYCRR 415.12(h)(1)

Plan of Correction: ApprovedNovember 3, 2016

What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
Resident #6: The incidents have been reviewed by the Administrator, Director of Nursing and ADON/Quality Assurance Coordinator. Resident?s plan of care reviewed for any necessary updates to prevent recurrence. Interventions to avoid unsafe wandering include wanderguard, 15 minutes checks, re-direction when displaying wandering behaviors by encouraging household activities and socialization.
Resident #31: The incident has been reviewed by the Administrator, Director of Nursing and ADON/Quality Assurance Coordinator. Resident?s plan of care reviewed for any necessary updates. Plan of care updated to include implementation of wanderguard to prevent recurrence and 15 minute checks for 24 hours to assess for any wandering patterns.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
? Full house audit will be completed to identify all residents exhibiting wandering behaviors.
? Care plan interventions for wandering behaviors to be reviewed for effectiveness and updated as needed.
? All areas secured with the wanderguard system are checked by security during the 7-3 shift to ensure proper functionality and are documented on the wanderguard test log. If system is not functioning properly, notification is made to maintenance and safety measures implemented as deemed necessary for at risk residents until system is properly functioning. In addition, the nursing staff on the 11-7 shift check each resident?s wanderguard bracelet using the wanderguard tester. If device does not function properly, supervisor is notified immediately for replacement. A current listing of all resident?s with a wanderguard bracelet along with his/her photo is available at the receptionist area and the security shack to identify those residents at risk for elopement. Occurrences in which security staff are not certain if person is a resident or visitor, they will approach to verify identity. If determined to be a resident security will alert receptionist and maintain safety while awaiting support staff.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
? Existing and new Interdisciplinary team members will be educated on the importance of ensuring thorough review of information when developing and evaluating care plan interventions pertaining to residents exhibiting wandering behaviors.
? Wandering incidents involving elopement attempts will be thoroughly investigated to ensure wanderguard systems are properly functioning and to ensure care plan interventions have been reviewed or updated to prevent recurrence.
? Nursing Supervisory staff will be educated on the investigative process, including review of plan of care to prevent recurrence and functionality of wanderguard system.
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?
? Audit will be conducted on each wandering incident involving elopement attempt to ensure thorough investigation has been completed and care plan has been reviewed or updated to prevent recurrence. This audit will be completed monthly for a total of 1 year to ensure 90-100% compliance. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assurance Committee on a monthly basis throughout the auditing period.
Responsible Person: Administrator

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 15, 2016
Corrected date: November 14, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (#NY 566), it was determined for 4 of 30 residents reviewed for abuse/neglect (Residents #6, 15, 25 and 30), for 1 additional resident (Resident #31), and for 3 of 5 newly hired employees reviewed (Employees #1, 3, and 5), the facility did not ensure all alleged violations involving mistreatment, abuse, and neglect were thoroughly investigated and that required pre-employment screenings was completed. Specifically, the facility did not conduct timely and thorough investigations into unsafe wandering (Residents #6 and 31), into dangerous resident behaviors (Resident #30), and into incidents of missing money (Resident #25). Additionally, the facility did not verify nursing staff's licenses before giving access to residents (Employees #1, 3, and 5); and did not report Resident #31's two altercations to the New York State Department of Health (NYS DOH) as required. - Employees #1, 3, and 5's licenses were not verified timely, prior to their having access to residents. - Additionally, when Resident #15 was involved in 2 altercations, the incidents were not reported to the New York State Department of Health (NYS DOH) as required. Findings include: DANGEROUS RESIDENT BEHAVIORS NOT THOROUGHLY INVESTIGATED: 1) Resident #30 had [DIAGNOSES REDACTED]. The 2/18/2016 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and did not exhibit behaviors during the assessment period. The comprehensive care plan (CCP) updated on 2/26/2016 documented the resident had impaired decision-making ability related to dementia, episodes of confusion and agitation, and exhibited behaviors that could cause harm to himself or others. Interventions included 1:1 supervision at all times and specified the resident should be within eye sight at all times to prevent harm to himself and others. The 3/18/2016 registered nurse (RN) Manager's (RN #1) progress note at 4:30 PM documented that an incident occurred on the 11 PM to 7 AM shift on 3/17/2016. The note documented certified nurse aide (CNA) #2 was assigned to provide 1:1 to the resident and when she was in the room with the resident he became frustrated so she sat outside of his room. CNA #2 reported she was outside for quite some time and when she re-entered the room, the resident had a call light cord around his neck. CNA #2 removed the call cord and tied it around the side-rail. RN #1 documented CNA #2 reported there were no further incidents that night. RN #1 documented she spoke with the resident who did not intend to harm himself, the call bell was replaced with a tap bell, and the plan included continuing 1:1 supervision on all shifts. The incident investigation initiated on 3/18/2016 by RN #1 documented: - on 3/17/2016 at approximately 2:15 AM, the resident was found by CNA #2 with the call bell cord around his neck. - The attached Record of Increased Resident Monitoring documented by CNA #2 the resident was in bed at 1:15 AM and the CNA was on break at 1:30 AM, 1:45 AM, 2:00 AM, and at 2:15 AM found the resident in bed with the call bell around his neck. - Licensed practical nurse (LPN) #3's undated statement documented she was not notified of the incident on 3/17/2016 and if she was notified, she would have reported it to the Supervisor immediately. - CNA #2's statement documented when the resident was agitated with her in the room she went and sat outside of the room. She documented after that she went on break and when she returned the resident had the call bell cord around his neck. CNA #2 documented it was wrapped around 3 times, she removed it, and wrapped it around the side-rail. CNA #2 documented she reported this to LPN #3 and CNA #4. - CNA #4 was asked to write a statement as well and that was not included with the investigation. - The Investigation Summary signed by the Director of Nursing (DON) and dated 3/19/2016 documented when CNA #2 re-enacted the incident, she was made aware that the call bell was loosely tied around the resident's neck and shoulder area and he was playing with the end of the call bell. The DON noted the resident was not exhibiting agitation and it was determined he was likely not trying to intentionally harm himself. The call bell was not removed at the time of the incident but the resident remained on 1:1 following the incident. The plan was to continue with safety interventions per plan of care. - The investigation did not document follow-up education with the staff members who did not report the incident timely; did not document a determination as to whether 1:1 was provided as planned as CNA #2 documented she was on break for the 45 minutes prior to finding the resident at 2:15 AM, and the investigation did not include a statement from CNA #4 who was also working on the unit at the time of the incident. RN #1 was no longer employed by the facility and was not available for interview. On 9/15/2016 from 10:30 to 10:33 AM, the surveyor attempted to contact CNA #2 and LPN #3 and return telephone calls were not received prior to survey exit. On 9/15/ at 12:03 PM, the DON stated in an interview, she did not ask CNAs #2 or 4 if the resident was in their line of sight prior to the incident because his 1:1 was not in place to prevent self harm, it was in place to prevent him from engaging in altercations with others. She stated when CNA #2 went on break, CNA #4 would have been expected to provide the 1:1 to the resident but she did not ask if that occurred. She stated CNA #4 was asked to submit a statement and that was not done. She stated there was no formal counseling or education provided to the staff members who did not report the incident timely as she could not prove that CNA #2 notified LPN #3 of the incident on 3/17/2016. UNSAFE WANDERING NOT THOROUGHLY INVESTIGATED: 2) Resident #6 had [DIAGNOSES REDACTED]. The 1/29/2015 physician's orders [REDACTED]. The 10/26/2015 comprehensive care plan (CCP) documented the resident had dementia and was a high risk for elopement. The resident ambulated the Adirondack neighborhood (the resident's unit), the health pavilion and throughout the whole facility. Interventions included the resident be checked every 15-minutes, a wanderguard applied, and she was to be redirected to her household as she does seek to exit the building. The 3/30/2016 elopement risk screen documented the resident had dementia, was fully ambulatory, wandered aimlessly, was difficult to redirect and had no history of elopement attempts. The screen documented the resident was to be watched for elopement. The 5/13/2016 at 9:24 PM nursing progress note documented the resident was seen by the front desk going out the door at 7:44 PM. A certified nurse aide (CNA), that was seated outside the door and on break, stayed with the resident and then returned inside without incident. The note documented the wanderguard system did not alarm when the resident went out the door and did alarm when she came back inside. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired, she ambulated with supervision and wandered 4 to 6 days of the assessment period. On 9/14/2016 at approximately 12:30 PM, the Director of Nursing (DON) was asked to provide the incident report for the resident's wandering on 5/13/2016. At 1:35 PM, the Administrator stated the resident was seen exiting the building by front door staff and because she was detected prior to exiting the building an incident report was not completed. There was no documentation the resident's wandering incident on 5/13/2016 was investigated and no documentation the care plan was reviewed or updated to prevent recurrence. On 9/15/2016 at 12 PM, the DON stated in an interview that yesterday was the first time she heard the resident wandered out the front door back in May. She stated the Supervisor was the only one aware it occurred and it was not reported IT because the resident was within eyesight when she exited the building. She stated that according to the Supervisor's note, the resident's wanderguard did not alarm and there was no follow up to determine why it malfunctioned. She stated she did not consider the incident an elopement, but it should had been investigated to determine why the wanderguard system failed. On 9/15/2016 at 1:05 PM, the Administrator stated in an interview that she learned yesterday the resident exited the building in (MONTH) and did not know what occurred at that time with the wanderguard system. She stated, the incident would had been investigated if she was notified. MISSING MONEY NOT THOROUGHLY INVESTIGATED: 3) Resident #25 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] and updated 8/18/2016, documented the resident was cognitively intact and required limited assistance for activities of daily living (ADL). The social worker's note dated 7/12/2016 at 9:51 PM, documented the resident was admitted to her current unit from the rehab unit on 6/29/2016. The resident was alert, oriented and able to effectively communicate her needs. The social worker documented the resident had a history of [REDACTED]. The 7/28/2016 at 2:11 PM social services progress note documented the social worker spoke with the resident's son about setting up a personal account, he would do that the following week as he was out of state, and the social worker would assist him as needed. The facility's policy Abuse and Adverse Incident Prevention and Reporting revised 8/2016, documented all alleged violations including misappropriation of resident property were to be reported immediately to the administrator of the facility. The 8/15/2016 at 5:15 PM social services progress note documented the social worker met with the resident as she reported missing money from her purse a few weeks ago. The social worker arranged to meet with security to take a report. The note documented the resident was to be encouraged to keep cash and valuables in her locked drawer. The 9/1/2016 at 2:56 PM social services progress note documented the resident's daughter expressed concerns about the resident's missing money and the social worker reviewed actions taken. When interviewed on 9/15/2016 at 10:30 AM, the resident stated she had money stolen from her. She said someone took 9 one dollar bills from her wallet and $60 (3- $20 bills) from an envelope in her purse. She stated she did not notice the money missing right away as she did not go into her purse every day. She stated she reported the missing money and told them about the woman she woke up to going through her drawers one night stating she was looking for Ben-Gay. On 9/15/2016 at 2:25 PM, the resident's missing money investigation was requested from the Administrator. The Administrator said she would call the Security Director to get a copy of the missing property report. On 9/15/2016 at 3:00 PM, the Administrator was interviewed and stated she was unable to find an investigations for the resident's missing money. She stated she had just spoken to the registered nurse (RN) Manager about the missing money. She stated she was told the resident told the RN Manager she was missing 9 one dollar bills from her wallet and the RN Manager contacted the social worker. The Administrator stated the RN Manager said the resident gave inconsistent statements regarding the missing money and a security officer met with the resident. On 9/15/2016 at 3:12 PM, the Security Director brought a daily activity report dated 8/15/2016. The report documented a security officer was called by the social worker to the resident's room at 2:00 PM on 8/15/2016. The officer documented a report was taken on 8/4/2016 for $9 missing, and today the resident reported $60 missing out of an envelope in her purse as well as her license and social security card. The resident said she put her purse in a blue bag and put it in the drawer next to her bed. She stated she woke up one night to find a woman going through her drawers who claimed to be looking for Ben-Gay. The report documented a missing property report was made for the resident's money. The Security Director was interviewed and stated he was unable to find a missing property report for 8/4 or 8/15/2016. He stated the investigations were kept in the Security Department and results of the investigations were verbally reported to administration. On 9/15/2016 at 3:14 PM, the social worker was interviewed and stated she was not involved with the investigation of the $9 missing. She stated the RN Manager had taken care of that and when she went to see the resident 3 or 4 days later, the resident told her she was missing $60. She said the resident told her she was also missing her drivers license and social security card. The social worker said she called security and stayed with the resident while security took a report. On 9/15/2016 at 3:27 PM, the Security Director brought a copy of the missing property report dated 8/4/2016 at 7:30 (AM or PM not specified). The report documented the resident stated she had 9 one dollar bills in her purse on Sunday (7/31) and on Tuesday (8/2) all 9 one dollar bills were missing. The report was completed by the RN Manager. The report form instructed to send the completed form to the Director of Safety & Security and the next section of the form Safety & Security Use Only was not completed. Attached to the report were 3 statements, 2 from certified nurse aides (CNA) and 1 licensed practical nurse (LPN), stating they had no knowledge of the missing money. When interviewed, the Security Director stated he was unable to find a report for the money reported missing on 8/15/2016. On 9/15/2016 at 4:15 PM, the Administrator stated it was not reported to her that the resident was missing money and she was unaware until the surveyor asked for the investigation. UNVERIFIED NURSING LICENSES: 4) The 12/2015 Hiring Process policy documented Human Resources was to check the NYS Education Department website to verify licenses and other abuse reporting websites prior to the first day of employment. The 4/2016 revised Abuse and Adverse Incident Prevention and Reporting policy documented Human Resources will check with the appropriate licensing boards and registries of all potential new hires. A) Employee #1, a licensed practical nurse (LPN), was hired on 5/9/2016. The documented license check for Employee #1 was dated 9/13/2016. The undated New Hire Checklist documented the employee completed the Criminal History record Check (CHRC, background check) forms on 4/20/2016, provided a copy of her LPN license on 4/26/2016, received her new hire confirmation letter on 4/26/2016, and began general orientation on 5/9/2016. The form did not document her LPN license was verified online by the facility. B) Employee #3, a registered nurse (RN) was hired 5/9/2016. The undated New Hire Checklist documented the employee completed the Criminal History record Check (CHRC, background check) forms on 4/4/2016, provided a copy of her LPN license on 4/13/2016, received her new hire confirmation letter on 4/13/2016, and began general orientation on 5/9/2016. The form did not document her RN license was verified online by the facility. The documented license check for Employee #1 was dated 9/13/2016. C) Employee #5, a licensed practical nurse (LPN), was hired 8/15/2016. The undated New Hire Checklist documented the employee completed the Criminal History record Check (CHRC, background check) forms on 8/5/2016, provided a copy of her LPN license on 8/11/2016, received her new hire confirmation letter on 8/11/2016, and began general orientation on 9/9/2016. The form did not document her LPN license was verified online by the facility. The documented license check for Employee #5 was dated 9/13/2016. When interviewed on 9/13/2016 at 3:00 PM, the Director of Human Resources stated the facility's education person was responsible for verifying staff licensure and certification. When interviewed on 9/13/2016 at 3:20 PM, the facility's education staff member #24 stated that she did not check licensure and certification as human resources provided her a copy of the license or certification and she believed them to be current. When interviewed on 9/13/2016 at 4:00 PM, the human resources staff member #25 stated she was not aware she was required to verify staff licensure and certification until a month ago. When interviewed on 9/15/2016 at 11:18 AM, the Director of Human Resources stated there was a change in some office personnel and there was a misunderstanding regarding who was responsible for verifying licenses. 10NYCRR 415.4(b)(1)(ii)(a),2,3,4

Plan of Correction: ApprovedNovember 3, 2016

What corrective action(s) will be accomplished for the resident found to have been affected by deficient practice?
Resident #6: The incidents have been reviewed by the Administrator, Director of Nursing and ADON/Quality Assurance Coordinator. Resident?s plan of care reviewed for any necessary updates to prevent recurrence. Interventions to avoid unsafe wandering include wanderguard, 15 minutes checks, re-direction when displaying wandering behaviors by encouraging household activities and socialization.
Resident # 15: The incidents have been reviewed by the Administrator, Director of Nursing and ADON/Quality Assurance Coordinator. Resident involved in 2 resident to resident interactions with another resident who was the aggressor in both instances. Resident?s plan of care reviewed and updates to include addition of risk for being a victim secondary to crying/yelling out behaviors and ambulating into other residents rooms. Interventions aimed at redirection added to plan of care including providing opportunities for increased ambulation, music and 1:1 socialization and offering diversional activities as per personal preferences as she will accept. Incidents were not reported to Department of Health as reflected in the Statement of Deficiencies. However, all future instances meeting reporting requirements as per the NYSDOH Nursing Home Incident Reporting Manual will be reported.
Resident #25: The incident has been reviewed by the Director of Security, Administrator, Director of Nursing and ADON/Quality Assurance Coordinator. Personal Fund Account was established on 9/1/16 and reimbursement for missing property was deposited into account on 9/19/16. As per Social Worker, resident has locked drawer in room and per resident she utilizes the drawer.
Resident #30: The incident has been reviewed by the Administrator, Director of Nursing and ADON/Quality Assurance Coordinator. Resident is no longer an active resident in the facility. 1:1 intervention was in place to monitor resident when exiting his room in order to provide increased monitoring to prevent him from engaging in negative altercations with others. At the time of the incident, staff were able to be positioned outside of resident?s room while providing 1:1 supervision as resident had no history of attempts to harm self. Alternate staff member is assigned to provide coverage during break time to ensure 1:1 supervision is maintained. Incident investigation revealed that resident was not attempting to harm self as evidenced by resident?s statement, interview of staff member describing positioning of the call light/resident playing with button on call light, and resident not exhibiting any additional signs or symptoms of suicidal ideation.
Resident #31: The incident has been reviewed by the Administrator, Director of Nursing and ADON/Quality Assurance Coordinator. Resident?s plan of care reviewed for any necessary updates to prevent recurrence. Plan of care updated to include implementation of wanderguard to prevent recurrence and 15 minute checks for 24 hours to assess for any wandering patterns. Incidents were not reported to Department of Health as reflected in the Statement of Deficiencies. However, all future instances meeting reporting requirements as per the NYSDOH Nursing Home Incident Reporting Manual will be reported.
How will we identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
? All residents are at risk for this deficient practice. Full house audit will be completed to ensure that all resident?s who wish to have a locked drawer and/or personal fund account have one available, and will provide assistance in obtaining such if necessary. Full house audit will be completed to identify all residents exhibiting wandering behaviors. Care plan interventions for wandering behaviors to be reviewed for effectiveness and updated as needed. Full house audit to be completed to identify current resident?s receiving 1:1 supervision, and re-education regarding the need for assigned coverage for break/meal periods to be provided. Administrator is responsible for ensuring incident reporting as per the NYSDOH Nursing Home Incident Reporting Manual.
What measures will be put in place or what systemic changes will you make to ensure that the deficient practice will not recur?
? The Abuse and Adverse Incident Prevention and Reporting policy was reviewed and no changes were necessary at this time.
? All staff will receive education on resident abuse, neglect, exploitation, mistreatment & misappropriation of resident property including the investigative process and reporting requirements (timeliness of reporting).
? All new staff will receive education during their orientation on resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property including the investigative process and reporting requirements (timeliness of reporting).
? Reported Concern of Alleged Abuse, Mistreatment or Neglect Guideline will be reviewed for any necessary revisions and will continue to be used as a tool to document alleged violations involving abuse, neglect, mistreatment, exploitation, misappropriation of property as well as investigative process.
? Nursing Supervisory staff will be educated on the Reported Concern of Alleged Abuse, Mistreatment or Neglect Guideline including the investigative process and review of plan of care to prevent recurrence.
? Missing Property Report and procedure will be reviewed for any necessary revisions. Existing and new security staff members will receive education on the procedure including investigative process and reporting.
? Existing and new Human Resource personnel involved in the hiring process will be re-educated on the requirements pertaining to online license verifications. Hiring process will be updated to include documentation of online license verification onto the New Hire Checklist.
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?
? Each alleged concern of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be documented onto the Reported Concern of Alleged Abuse, Mistreatment or Neglect Guideline form. This form will be audited for completion and compliance with the Abuse and Adverse Incident Prevention and Reporting policy. This audit will be completed monthly for a total of 1 year to ensure 90-100% compliance. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assurance Committee on a monthly basis throughout the auditing period.
? Audit tool will be developed to ensure online license verifications completed and documented prior to first day of employment. This audit will be completed monthly for a total of 1 year to ensure 90-100% compliance. If sustained compliance is not achieved, auditing will continue. Audit will be reported to the Quality Assurance Committee on a monthly basis throughout the auditing period.
Responsible Person: Administrator