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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 5, 2024
Corrected date: N/A
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, | 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: N/A
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/ 2018. There was no documented evidence that an annual performance evaluation was completed after 2018. 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: 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: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during an abbreviated survey (NY 050), the facility did not ensure that all alleged violations involving abuse, and neglect are reported immediately but no later than 2 hours to the New York State Department of Health (NYS DOH). This was evident for 1 of 3 residents (Residents #1) reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/21/2024 left the facility undetected by facility staff on 11/26/ 2024. The Facility staff did not realize Resident #1 was not in the facility until dinner time (approximately 5:30pm-6pm) and did not report the incident to State Agency Department until 11/27/ 2024. The findings are: The Facility Policy on Accident-Incidents created 11/2013 documented that it is the facility policy to monitor and evaluate all occurrences of accidents or incidents or adverse event occurring on the facility premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated. Director of Nursing and Administration are responsible to review incident/investigation and conclusion to determine if incident requires reporting to outside agencies such as Department of Health, OIG CMS etc. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating impaired cognition with decision making. Resident was independent with activities of daily living and was ambulatory. 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. The Facility Incident Report dated 11/26/2024 documented that late afternoon on 11/26/2024, the resident was noted as missing from the unit. Code Gray was initiated with an unsuccessful outcome of the facility search. A call was made to 911 as well as notification to the next of kin. A thorough search of facility, grounds and surrounding area was unsuccessful. Investigation findings documented 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 is reasonable cause that abuse, neglect, exploitation or mistreatment may have occurred. The incident was reportable to the Department of Health. During an interview conducted with the Administrator on 12/3/2024 at 1:53pm, the Administrator stated the facility became aware of the incident on 11/26/2024 at 6:00pm. The facility reported the incident to the New York State Department of Health on 11/27/2024 at 1:11AM. The Regional Nurse submitted the report. . 10NYCRR 415. 4(b)(1)(i) | 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. |