Eastchester Rehabilitation and Health Care Center
August 6, 2018 Complaint Survey

Standard Health Citations

FF11 483.12(b)(1)-(3):DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95,

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 6, 2018
Corrected date: October 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 718), the facility did not provide in-service and training to existing nurse aides that include how nurse aides would understand behavioral symptoms of residents that may increase the risk of abuse, and how nurse aides had to respond. This was evidenced in 1 out of 4 residents sampled (Resident #1). Specifically, Certified Nursing Assistant #1 (CNA #1) was assigned to perform one to one supervision for Resident #1 on 04/04/2018. CNA #1 attempted to redirect Resident #1 and the resident became physically aggressive with the CNA. CNA #1 pushed Resident #1 away from him and the resident fell on his back; sustained a 3cm laceration to the back of his head. Record review revealed that CNA #1 did not receive training on how to understand behavioral symptoms and how to respond to the physically aggressive resident. CNA #1's personnel file revealed that the CNA was last in-serviced on abuse prevention 08/25/2014. The Findings are: The Facility's Policy and Procedure on Abuse Prevention and Reporting dated 03/2018 documented that the resident will be free of abuse. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, consultants or volunteer staff of other agencies. The facility will maintain a system in place to protect the residents from abuse and to protect the health and safety of the resident. It is documented that regularly scheduled in-service training programs are designed to teach staff how to better understand the resident's abusive actions. It is also documented that upon hire, annually, and as needed, all facility employees will receive in-service education on Abuse, Reporting, Behavior Management and care of the Resident with Dementia. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool), dated 03/12/2018 documented that the resident had severely impaired cognition (never/rarely made decisions). An Admission's Assessment note dated 03/05/2018 documented that Resident #1 was at risk for abuse secondary to Dementia and Alzheimer's. Resident #1 was unable to tolerate frustration and acted out impulsively. A Comprehensive Care Plan (CCP) dated 03/12/2018 documented that Resident #1 was care planned for the potential for exhibiting inappropriate behavior as evidenced by [MEDICAL CONDITION]. The interventions documented that the staff should identify patterns in the resident's behavior, document in the progress notes; the intensity, duration or frequency of the behavior. Encourage the resident to participate in activities of daily living (ADLS), notify the physician immediately of behavior and refer to the psychiatrist. Provide redirection or distraction to minimize frequency or duration of behavior. A Resident CNA Documentation Record dated 03/05/2018, revealed no instructions on how the CNAs are to understand and respond to Resident #1's physical aggression. The nurses' notes dated from 03/11/2018 to 03/14/2018 documented that Resident #1 was aggressive towards staff and difficult to redirect. The resident had excessive agitation and/or debilitating restlessness and showed physical aggression towards caregivers. A nurse's note dated 03/16/2018 at 8:47 AM documented that at around 7:30 AM, Resident #1 filled the toilet with diaper and toilet tissue. During redirection, the resident fought, hit and scratched the staff. A nurse's note dated 03/17/2018 documented that Resident #1 was alert and restless most of the evening. [MEDICATION NAME] given with no effects and one-on-one was unsuccessful. A nurse's note dated 03/18/2018 documented that Resident #1 continued with increased restlessness and agitation. The resident kicked, bit, and scratched at the staff. A nurse's note dated 03/20/2018 documented that Resident #1 was restless throughout the tour. He kicked and scratched the staff. Medication given with no effects. A nurse's note dated 03/21/2018 documented that the resident was restless and combative at times. He kicked and bit the staff during care; gentle approach was ineffective. A nurse's note dated 03/23/2018 documented that Resident #1 defecated in his roommate's garbage can. The resident was unable to understand instructions and redirection. A nurse's note dated 04/01/2018 documented that shortly after 6:30 AM, a CNA heard Resident #1 in another resident's room calling out get this man out of here. Resident #1 was naked from the waist down. He was escorted back to his room and was dressed. Resident #1 again wandered into another resident's room. The supervisor, Social Worker (SW) and medical doctor to follow up. A nurse's note dated 04/02/2018 documented that Resident #1 was combative towards staff when they redirected him. A nurse's note dated 04/03/2018 (night shift) documented that Resident #1 was restless and physically aggressive. Resident #1 hit both CNAs as they were attempting to escort him to his room. A nurse's note dated 04/03/2018 (evening shift) documented that the resident was physically aggressive towards staff. The resident punched a staff in the arm and cursed at them. A Social Worker's (SW) note dated 04/03/2018 documented that Resident #1 was very difficult to redirect as he does not follow directions well. Review of the facility's surveillance camera, revealed that on 04/04/2018 at 6:35 AM, CNA #1, who was assigned to provide one-on-one monitoring for Resident #1, was with the resident in the dining room. Resident #1 was pulling the wet ones from a container and was tossing them in the dining room. CNA #1 attempted to redirect him and Resident #1 became physically aggressive. Resident #1 was throwing fast, repetitive punches at the CNA. CNA #1 had his hands held up attempting to block the punches as he was backing away from the resident. Resident #1 pursued CNA #1 with continuous punches. The CNA continued to back away with his hands held up and extended (blocking the punches). However, one of the resident's punches connected with the CNA's lower left cheek. CNA #1 raised his left leg, further extended his arms touching Resident #1 on the chest, and pushed the resident away from him. Resident #1 fell on his back and the CNA went into the hallway and motioned for assistance. As the staff attempted to apply First Aid, Resident #1 became physically aggressive with the staff. The resident twisted the nurse right hand and punched her in the chest. Two other staff members were punched in the face and chest. Staff were observed running away from Resident #1. A nurse's note dated 04/04/2018 at 7:21 AM documented that at around 6:35 AM, CNA #1 approached the nursing station and reported that Resident #1 fell and was bleeding from the head. Resident #1 was assessed and had no complaints of pain. Mild bleeding noted from the laceration at the back of the resident's head. Resident #1 twisted the nurse's right hand and punched her in the chest as she was providing treatment. Two other staff members were punched in the face and chest. The resident was transferred to the hospital. A Physician's note dated 04/04/2018 documented that the resident was observed on the floor in the dining room, sustained superficial laceration 2cm, to the back of the head. The resident was sent to the Emergency Department (ED) for CT-Scan of the head. The resident returned to the facility and his condition was stable. Staff to maintain safety precaution and one to one protocol for wandering behavior. Registered Nurse Unit Manager #1 (RNUM #1) was interviewed on 06/08/2018 at 11:40 AM and stated that Resident #1 was aggressive to CNA #1. Resident #1 punched and hit the CNA while they were in the dining area. Assessment revealed that Resident #1 sustained a laceration to the back of his head with minimal amount of bleeding. During assessment, Resident #1 continued to be aggressive. The physician was informed and ordered that Resident #1 be transferred to the hospital for further evaluation. Resident #1 was on one to one supervision due to his aggressive and combative behavior. The RNUM does not know if CNA #1, who was assigned to provide one to one supervision to Resident #1 (first time assigned to the resident) had prior training on how to handle the resident during his aggressive behavior. She was not aware if any of the staff received training on how to handle aggressive residents. CNA #1 was interviewed on 06/11/2018 and on 07/16/2018 and stated that he was never assigned to provide care to the residents on the units. His duties mainly consisted of escorting residents to and from clinical appointments, monitoring residents in the dining room and at times provided one to one supervision. It was his first time providing one to one supervision to Resident #1. A nurse instructed him, don't let the resident fall, don't let the resident get up and don't hit the resident. At around 6:30 AM, he was monitoring Resident #1 in the dining room when the resident started pulling wet wipes from its container and was throwing them. He attempted to redirect Resident #1 and the resident became physically aggressive. The resident was punching at him as he was trying to move away. He was just trying to get away from the resident. He stated, I did not scream for help, I thought the resident would calm down and it happened so quickly. Resident #1 fell because he was wearing socks. After the resident fell , he was still punching, scratching and hitting at the staff as they tried to provide First Aid. He provided one to one monitoring for other residents, but they never acted like this resident (Resident #1). I didn't know he would act like this. He does not remember the last time he received in-service on abuse prevention and that he never received training on how to handle the residents when they acted like this (aggressive and combative). A Licensed Practical Nurse (LPN) was interviewed on 06/11/2018 at 2:45 PM and stated that Resident #1 was on one to one supervision because of his wandering and aggressive behavior. On 04/04/2018 at approximately 6:00 AM, the resident was awake and went to the dining room with the CNA that was providing one to one monitoring. CNA #1 came to her and reported that the resident fell in the dining area. She went to check Resident #1 and observed him on the floor bleeding. Resident #1 was hitting the staff as pressure dressing was being applied to the site. CNA #1 did not inform her that Resident #1 was being aggressive or that the resident hit him. She stated that she informed CNA #1 that Resident #1 was aggressive and that he should monitor the resident and report to the Charge Nurse (CN) or the supervisor if the resident was aggressive. She received in- service on abuse prevention but unable to recall if she had received in-service on how to deal with the aggressive resident. A Charge Nurse was interviewed on 06/11/2018 at 3:23PM and stated that Resident #1 returned to the facility status [REDACTED]. There was no bleeding noted and there were no changes in mental status. She was not familiar with the resident as she floated to the unit on 04/04/2018 post incident. Resident #1 was on one to one supervision because of his aggressive behavior. He wandered around the unit and got physically aggressive when redirected. The facility provided in-service on abuse prevention, but she does not remember receiving in-service on how to deal with the combative resident. The In-Service Coordinator was interviewed on 07/26/2018 at 11:10 AM and stated that she does not recall the staff receiving in-service or training on how to handle/approach aggressive and combative residents. She stated that she could not find a current in-service on abuse prevention for CNA #1. A follow-up interview was conducted with the In-Service Coordinator on 08/06/2018 at 9:46 AM. She stated that she is the wound care nurse for the facility and she assumed the position of In-Service Coordinator 01/2016. She is responsible for ensuring that all the staff receive in-services on abuse and how to care and manage cognitively impaired residents as well as how to manage residents with behavior problems in the long-term care unit. Facility and agency staff received in-services during orientation and mandatory in-services are provided annually to all staff. Staff received in-service on abuse prevention 01/2017. However, there were no in-services on Dementia Management and or training for staff understanding of how to handle aggressive residents to prevent abuse. The Director of Nursing Service (DNS) was interviewed on 07/16/2018 at 2:32 PM and stated that it is the nurse's discretion to provide one to one supervision when a resident is aggressive and combative. The CNA who provided one to one supervision was given verbal instructions on how to deal with the aggressive resident. CNA #1 did not have an updated in-service on abuse prevention (last in-service 08/25/2014) and the nursing staff did not receive in-service on how to manage the physically aggressive resident. A follow-up interview was conducted with the DNS on 07/17/2018 at 10:00 AM. The DNS, stated that it is the responsibility of the facility to give in-services to all agency staff and that mandatory in-services are conducted once a year. The staff working on the long-term unit must receive in-service on Dementia Care. The facility does not have a policy regarding the in-servicing and training of staff. 415.(b)(7)(b)

Plan of Correction: ApprovedAugust 21, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A. As stated in the SOD Resident # 1 was hospitalized and returned same day. Laceration was clean and without signs and symptoms of infection. Upon readmission the attending physician examined him and ordered 1:1 monitoring and neuro checks to continue. The resident was confused and wandered aimlessly without safety awareness. The next morning, 4/5/18, the daughter visited and stated that the resident had injured his back. The nurse completed a full body assessment and other than the laceration in the occipital area there was no other visible injury. However, resident grimaced when sacral/coccyx area was touched. MD was notified and ordered an x-ray of the area. The daughter called the police and requested an ambulance because she preferred the hospital to do the x-ray. Resident was transferred to the hospital and has not been returned to the facility. That night the daughter came and took all his belongings.
B. CNA #1 was immediately counselled by the DNS and suspended during investigation of the incident. The CNA has not returned to the facility for employment.
2. The RN Managers will conduct a medical record audit of all residents with a [DIAGNOSES REDACTED]. All CNA accountability records will be updated to include patient centered instructions on how to respond and understand the resident?s behavior.
3. A. The QAPI Committee reviewed the policy and procedure on Abuse Prevention and found it to be compliant.
B. All facility employees will be re-inserviced on the policy and procedure by the inservice director. All employees will receive the inservice upon hire and at least annually.
C. The QAPI Committee reviewed the policy and procedure for Dementia care and services and found it to be compliant.
D. All nursing employees will be re-inserviced on the policy and procedure by the inservice director. All nursing employees will receive the inservice upon hire and at least annually.
E. The QAPI Committee reviewed the policy and procedure on Behavior Management and
revised the policy to include instructions on how to respond and understand the behavior on the CNA accountability record of applicable residents.
F. All nursing employees will be inserviced on the newly revised policy and procedure by the inservice director. All nursing employees will receive the inservice upon hire and at least annually.
G. The QAPI Committee developed and implemented a policy and procedure on Inservice Education for Employees.
H. All employees will be inserviced on the newly developed policy and procedure.
4. A. An audit tool was developed by the QAPI Committee to monitor inservice training on Abuse Prevention, Dementia Care and Services, and Behavior Management to ensure that employees receive the inservices upon hire and at least annually. The audit will be conducted by the DNS/designee on all employees at the time of new hire and annually thereafter. All findings will be reported to the QAPI Committee. Any negative findings will be reported to the Administrator and QAPI Committee for immediate action.
B. An audit tool was developed by the QAPI Committee to monitor and ensure that the CNA accountability record includes documented instructions on how to respond and understand the behavior of residents with [DIAGNOSES REDACTED]. The audit will be conducted by the DNS/designee on all applicable residents weekly x 4 weeks, monthly x 3 months and then as directed by the QAPI Committee. All findings will be reported to the Administrator and QAPI committee. Any negative findings will be corrected immediately.
5. The DNS will be responsible for compliance.