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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2024
Corrected date: January 9, 2025
Citation Details Based on record reviews and interviews during an abbreviated survey (NY 050), the facility did not ensure Certified Nurse Aide performance appraisals were completed at least once every 12 months for 2 of 3 Certified Nurse Aides record reviewed. Specifically, performance appraisals were not documented every 12 months for Certified Nurse Aide #2 and # 3. The Findings are: The Facility Policy on Employee Evaluations created 9/2019 documented the job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at least annually. The completed performance evaluation will be placed in the employee's personnel record. Review of Facility Personnel Records revealed Certified Nurse Aide #2 was hired 7/1/ 2022. There was no documented evidence of any annual performance evaluation since date of hire. Review of Facility Personnel Records revealed Certified Nurse Aide #3 was hired 6/20/2017 and performance evaluation was conducted 9/5/ (YEAR). There was no documented evidence that an annual performance evaluation was completed after (YEAR). During an interview on 12/4/24 at 11:00am with the Director of Nursing, they stated that performance evaluations are done by the Director of Nursing and Director of Human Resources . They have been in the facility for 2 months and have not completed any performance evaluations for the staff. During an interview on 12/4/24 at 11:26 am with the Director of Human Resources, they stated that annual performance evaluations for employees are completed by Nursing. Human Resource performs a review and notifies the nursing department if evaluations are not completed. The Director of Human Resource reviewed Certified Nurse Aide #2 & 3's employee file in the presence of the surveyor. The Director for Human Resources could not provide documentation for a recent annual performance evaluation for Certified Nurse Aide #2 and # 3. The Director for Human Resource stated the annual performance evaluation for Certified Nurse Aide #2 and #3 were not completed according to the facility policy. 10 NYCRR 415. 12(h)(1) | Plan of Correction: ApprovedJanuary 10, 2025 Resident #1 remains in Los Angles. Upon return to facility resident will be re-evaluated for elopement risk with update care plan and interventions All residents with wander guards, exiting seeking behaviors, and those spending excessive time off the unit in the lobby or recreation room have the potential to be affected. All residents with wander guards, high risk for elopement, exit seeking behaviors, and those who spend excessive time off units were re-evaluated for elopement risk and audits and chart reviews completed. Elopement Binders, Care plans, and interventions were updated accordingly. The facility policy on Elopement Prevention was reviewed by the Administrator and Director of Nursing and determined to in compliance with state and federal guidelines. No revision made. Staff Educator /designee will educate all staff on facility policy on Elopement Prevention with focus on closely supervising resident high risk for elopement. Unit sign-in/out sheets at nursing stations were implemented to account for residents being taken on or off the unit by rehab, recreation, etc. Staff rounding tool was implemented to account for unit residents during the shift, indicating resident location. Residents identified as high risk for elopement and are non-compliant with wander guard will receive enhanced monitoring/supervision every 1-3 hours. Staff Educator/Designee will in-service all staff on implemented procedures and forms. Front desk staff re-educated on emergency codes, monitoring of lobby, elopement policy and awareness of door alarms. Facility elopement drills will be conducted weekly x 4 weeks and then monthly. The audit results will be submitted to the monthly QAPI meeting for review and recommendations. The Responsible Party: Assistant Administrator. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2024
Corrected date: January 9, 2025
Citation Details None | Plan of Correction: ApprovedDecember 27, 2024 Certified Nurse Aide #2 yearly performance review was conducted on 12-20-24 Certified Nurse Aide #3 yearly performance review was conducted on 12-20-24 The facility conducted an audit of all employees' files. Director Human Resources/Designee and department manager will ensure all identified employees with outstanding yearly evaluation be completed by 1/8/25 Policy and Procedure was reviewed on 12/19/24 for yearly evaluations. No revisions made. Director of Human Resources, Department Heads and Managers were educated on 12/20/24 on the importance of conducting employee yearly evaluation The Director of Human Resources/ Designee will conduct weekly audits and to track and meet with all employees who are due for yearly evaluations. Director of Human Resources/ Designee will meet with department manager and employee to complete evaluation in accordance with the facility policy and procedure. Director of Human Resources will conduct weekly audit x3 months, then monthly x3 months. The audit results will be submitted to the monthly QAPI committee for review. The Responsible Party: Director of Human Resources. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2024
Corrected date: January 9, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during an abbreviated survey (NY 050), the facility did not ensure that residents were provided adequate supervision/monitoring to prevent elopement. This was evident for 1 of 3 (Resident #1) residents reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/12/2024 exited the facility through the front door on 11/26/2024 at approximately 11:30 am undetected by facility staff. The resident was found on 12/2/2024 by Los Angeles Police Department who called the facility to report that the resident was brought to Los Angeles Police Department General Psych for evaluation. The findings are: The Facility Policy on Elopement Prevention created on 7/2024 documented the facility maintains a process to identify residents at risk for elopement, implement preventative strategies for those identified as an elopement risk and conduct a missing resident procedure when necessary. Interventions that may be implemented for residents identified at risk for elopement may include but are not limited to frequent monitoring of the resident's whereabouts to ensure they remain in the facility, implementation of a wander management device or other electronic alert system. The Facility Policy on Care Plans - Comprehensive created on 10/2015 documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will incorporate risk factors associated with identified problems. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented Brief Interview Mental Status score of 10 indicating impaired cognition with decision making, no impairment of upper & lower extremities, no mobility device and was independent with activities of daily living. Review of the Risk for Elopement Care Plan updated 10/21/2024 documented resident exhibited potential risk for elopement such as going to unsafe areas, risk of injury to self and others, exit seeking, fixation on meeting with mail staff and refusing wander guard. Review of the Quarterly Elopement evaluation dated 10/12/2024 documented Resident #1 scored 16 as high risk for elopement, not a candidate for wander management device. If the total score is 10 or greater, the resident should be considered to be at high risk for elopement. Prevention protocol should be followed and documented on the care plan which includes enhanced monitoring for exit seeking behavior. The evaluation documented the resident was currently exit seeking. There was no documented evidence that Resident #1 was closely supervised and monitored frequently prior to the incident on 11/26/ 2024. The Facility Incident Report dated 11/26/2024, documented that on 11/26/2024 during the late afternoon, Resident #1 was noted as missing from the unit. A Code Gray was initiated with an unsuccessful outcome from the facility search. A call was made to 911and the next of kin was notified. A thorough search of facility grounds and surrounding areas was conducted and unsuccessful. Investigation findings documented the resident went to the lobby downstairs at approximately 11:30 am to sit by the window to wait for the mailman. At the close of the investigation, the facility determined that the resident exited through the front door during a high traffic period of a holiday week, while the reception staff was occupied. The investigation revealed that there was reasonable cause that abuse, neglect, exploitation or mistreatment may have occurred. The incident was reported to Department of Health and all staff involved were suspended pending investigation completion. Review of an addendum to the Facility Incident Report documented that on 12/2/2024 at 11:49 pm, Resident #1 was located in Los Angeles California at the Los Angeles Police Department Olympic Division. Resident #1 was admitted to the Los Angeles General Psychiatric Center. According to the officer, Resident #1 took a train to Manhattan and then purchased a bus ticket at Port Authority. Resident #1 proceeded to take a bus from New York to Los Angeles. Review of the Receptionist/Front Desk staff on duty statement documented on 11/26/2024 at 11:30am they saw the resident sitting by the window, once the mailman arrived the resident gave the mailman their mail. The Receptionist documented they thought the resident went to the restroom and did not see the resident again. Review of Certified Nurse Assistant #1 statement documented that they worked the 7:00am - 3:00pm shift and 3:00pm -11:00pm shift on 11/26/ 2024. Resident #1 was assigned to them on both shifts, but they did not provide care to the resident as the resident was independent with activities of daily living. The resident ate breakfast & lunch in their room. Resident #1 usually went downstairs for activities. At 5:00pm as they were giving out dinner trays, they were told by Certified Nurse Assistant #3 that Resident #1's lunch tray was still in their room. Certified Nurse Assistant #1 and Certified Nurse Assistant # 3 reported this to the nurse immediately. Review of Certified Nurse Assistant # 2 statement documented that they worked 7:00am -3:00pm shift and 3:00pm -11:00pm shift but Resident #1 was not assigned to them. Certified Nurse Assistant # 2 documented they went to deliver the meal tray and did not see Resident #1 in their room. Normally Resident #1 is in their room at dinner time. Certified Nurse Assistant #2 reported to the nurse & they began immediately looking for the resident. Review of Certified Nurse Assistant #3's statement documented Resident #1 was not in their room, but their tray was there. They thought the resident went to activities. At dinner time they went to give dinner trays and the resident was not in their room. They reported it to the nurse and began searching for the resident. Review of Licensed Practical Nurse #5's statement documented that on 11/26/2024 they made rounds at 4:30pm and noted Resident #1 was not in their room but did not find it unusual. At 5:00pm Certified Nurse Assistant # 3 told them Resident #1 was not in their room. Licensed Practical Nurse #5 documented they searched the room. During an interview conducted on 12/3/2024 at 1:53pm with the Administrator, they stated they were not in the facility when the incident occurred but was informed by the Director of Nursing. Staff interviews were obtained and reviewed by the Director of Nursing on 11/26/ 2024. The Administrator stated the cameras in the lobby are not functional. There are no recordings and there is no live feed. The Administrator stated they were not sure if there is a camera in the parking lot or driveway. The Administrator stated that the Regional Nurse submitted the incident report to Department of Health on 11/27/2024 at 1:11 am. During a subsequent interview on 12/3/2024 at 3:43 pm with the Administrator, they stated that the Assistant Administrator supervises the receptionist. The Administrator stated the Director of Nursing reported to them that an officer found a person that fit the description of the resident on the street, and they asked the officer to take them to the train station because they needed to go to the Port Authority Station. The officer escorted the individual to the train station as requested. The Administrator stated the officer described the individual as presenting well and had 2 bags, black coat and had shoes on. The Administrator stated Resident #1 withdrew one hundred dollars from their account on 11/22/ 2024. The Administrator stated Residents who are at risk for elopement are supervised closely and frequently monitored every 1-3 hours. The Administrator could not provide any documentation for the supervision provided to Resident #1 prior to the incident on 11/26/ 2024. During a telephone interview on 12/4/2024 at 8:45 am with Certified Nurse Assistant #2, they stated that they worked on the 2nd floor on 11/26/2024 and it was a very busy day giving care, serving trays, collecting trays, feeding residents. Certified Nurse Assistant #2 stated they saw Resident #1 during breakfast time around 8:30am - 9:00am sitting on their bed eating. Resident #1 usually ate in their room for all 3 meals breakfast lunch, and dinner. Certified Nurse Assistant #2 stated they did not see the resident again after 9:00am. Certified Nurse Assistant #2 they did not give Resident #1 a lunch tray and did not pick Resident #1 lunch tray. Certified Nurse Assistant #2 stated that they knew Resident #1was missing in the afternoon approximately 4:00pm-5:00pm pm because they kept passing by the resident's room and did not see the Resident. Certified Nurse Assistant #2 stated they informed Certified Nurse Assistant #3 that Resident#1 was not in their room. Both Certified Nurse Assistant #2 and Certified Nurse Assistant #3 checked the resident's bathroom, alerted the nurse and they began to look for Resident#1 about 5:00pm. The nurse alerted all the Certified Nurse Assistants to check all the rooms. Certified Nurse Assistant #2 stated they checked all floors and could not find Resident # 1. During a telephone interview on 12/4/2024 at 9:14 with Certified Nurse Assistant # 3, they stated they worked the 3:00pm - 11:00pm shift on 11/26/ 2024. Certified Nurse Assistant #3 stated they came in at 3:00pm, made rounds and checked rooms. Certified Nursing Assistant #3 stated they thought Resident #1 went to activity after they checked the residents' room and Resident #1 was not in their room, as Resident #1 goes to the lobby for activity. Certified Nursing Assistant #3 stated they realized at dinner time after 5:00pm pm that Resident #1 was not in their room. Certified Nursing Assistant #3 stated they reported to Licensed Practical Nurse #5 after 5:00pm that Resident #1 was not in their room. They all began to look for Resident # 1. During an interview conducted on 12/4/2024 at 9:53 am with Licensed Practical Nurse # 5, they stated they worked on 11/26/2024 when they were asked to come in and cover the shift. Licensed Practical Nurse #5 stated they made rounds about 4:30pm to check on the residents and did not see Resident #1 but it was not unusual for Resident #1 not to be there in their room because sometimes the resident goes downstairs for recreation. Licensed Practical Nurse # 5 stated a little after 5:00pm, Certified Nurse Aide # 3 while passing out the dinner trays reported that Resident #1 was not in their room. Licensed Practical Nurse # 5 stated they asked Certified Nurse Aide #1 and Certified Nurse Aide #2 who worked the day shift where Resident #1 was. Licensed Practical Nurse # 5 stated they all began to search the room for the resident, and they checked the computer to see if the resident went out on pass but there was no note indicating the resident was out on pass. Licensed Practical Nurse # 5 stated the policy of nursing home for missing residents is to start looking for the resident and call the supervisor. Licensed Practical Nurse # 5 stated they went downstairs and found the Director of Nursing who was already aware of the situation. Licensed Practical Nurse # 5 stated they heard Code Gray called but does not remember the exact time it was called. Resident #1 was not found. Resident was monitored during rounds every 3 hours. During an interview on 12/4/2024 at10:36 am, Receptionist # 4 stated that they worked the 8:00am - 4:00pm shift on 11/26/ 2024. The day shift is always busy. Receptionist # 4 stated they answer the phones open doors, listen to family concerns, complete paperwork for residents out on pass, transfer phone calls. Receptionist # 4 stated they saw Resident #1 at the lobby around 11:30am sitting waiting for the mail which was their normal routine. Receptionist # 4 stated they saw Resident # 1 handing their mail to the mail man and walk past the desk towards the elevator. Receptionist # 4 stated they are not sure if Resident # 1 went to the bathroom. Receptionist # 4 stated they do not recall the exact time. They left the facility at 4pm and the facility called at 6:00 pm, they were called and asked if they saw Resident # 1. During an interview on 12/4/2024 at 12:52pm with Social Worker, they stated Resident #1 never attended any care plan meetings and always declined invitations. There is no plan for discharge for Resident # 1. Resident #1 was a Long-Term resident who comes down to the first floor and wait for the mailman. Resident's usual routine is at the lobby between 11:00am -12:00 pm to wait for the mailman. Social worker stated Resident #1 spoke about when they were a ballerina, and the resident seemed content in the facility and never tried to leave or express any desire to leave, was happy and wanted to remain in the facility. During an interview on 12/4/2024 at 4:00pm with the resident's representative, they stated they communicated with Resident #1 only by mail and that they only exchanged letters. They never spoke on the phone. Resident #1 had expressed that the place is like a prison because they are locked up. Resident's representative stated that they told the resident the place is the best place for them because they take good care of them, and it is not a prison. Resident#1's representative stated they never informed the facility about what the resident expressed, because they thought it was private matter between them and their sister. Resident's representative stated on average they get a letter from resident once a month or every other month. Resident's representative stated they got a call from the White Plains Police Department to inform them that the resident was found in Los Angeles. Resident representative stated that resident used to live in Los Angeles for [AGE] years by themself and then they were evicted and found themselves in New York during wintertime, was screaming out of control and the Police took the resident into the court system. During an interview on 12/4/2024 at 5:18pm with the Director of Nursing, they stated that on 11/26/2024, they saw Resident #1 at 12:15pm or 12:30pm at the lobby by the window facing the parking lot. At 7:00pm White Plains Police officer came to the facility to collect additional information about the resident and asked for a description which was provided by the Director of Nursing. The Director of Nursing stated that they gave the officer a description of what the resident was wearing which was dark pants/blue or black top and sneakers but did not see the resident with bags. At 10:00 pm the officer returned to the facility to inform the Director of Nursing that Eastchester Police escorted someone who may fit the resident's description to the train station. No specifics were provided. The Director of Nursing stated they called the Administrator when Code Gray was activated a little after 6:00pm. Staff told the receptionist to call the code. The facility protocol for calling a code gray is for staff to speak to the supervisor if resident is not on the unit, or in their room or in rehab. The Supervisor will instruct the receptionist to call the code. The Director of Nursing confirmed that the facility had no knowledge that Resident #1 had left the building. During an interview with the Administrator on 12/5/2024 at 9:24 am, and also at 11:39 am and Administrator stated that the wander guards are checked for Function every night by the Registered Nurse supervisor and documented in the binder. The wander guard location/placement is checked every shift by the unit nurse and documented in the Treatment Administration Record. The Administrator stated the facility is ensuring that all residents are safe by asking them to wear the wander guard. The Administrator stated that all the residents at risk for elopement are wearing wander guards. 10 NYCRR 415. 12(h)(1) | Plan of Correction: ApprovedDecember 27, 2024 The elopement incident for resident # 1 was reported on 11/27/ 24. All facility DOH reportable events have the potential to be affected by this deficient practice. All DOH reported incidents were reviewed for the past 30 days. Facility policy on Accident/Incidents was reviewed by the Administrator and Director of Nursing and determined to in compliance with state and federal guidelines. No revision made. Staff Educator/designee will educate all staff on facility policy of Accident and Incidents and timely reporting requirements. The in-service will focus on reporting incidents to the Administrator and DON immediately, reporting requirements of 2 hours to the DOH for reportable events. The Administrator/designee will audit all reported incidents for compliance with the 2-hour reporting time frame. The audits will be completed weekly x 4 weeks, then monthly until compliance is met. The results of these audits will be submitted at monthly QAPI to the committee for review. The administrator is responsible for the execution of this plan of correction. |