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Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: March 10, 2025
Corrected date: April 17, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (NY 790), the facility did not implement a comprehensive person-centered care plan for 1 of 3 residents reviewed for Neglect. Specifically, the resident required 2-person assistance for bed mobility, however bed mobility was provided with one person assistance. The resident was injured sustaining head trauma and laceration to the left forehead during bed mobility performed with the physical assistance of 1 person. The findings are: A review of the undated facility Policy and Procedure titled, Activities of Daily Living (ADL) support documented that appropriate care and services will be provided for residents unable to carry out ADLs independently in accordance with their plan of care including appropriate support and assistance with hygiene, elimination, and mobility. A review of the undated facility Policy and Procedure titled, Care Plans documented the care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being provided by qualified persons. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 5/13/22 documented that the resident had a severe cognition impairment. The assessment documented that the resident required extensive assistance of two staff for bed mobility, dependent assistance of two staff for transfers, dependent of one staff for dressing and toilet use and hygiene, and extensive assistance of one staff for eating. A review of the facility Accident / Incident Investigation dated 7/7/22 includes the TNA's statement which documented that the TNA was caring for the resident, rolled her over to get the brief from under her, and the resident's upper body slipped out of the bed, and she fell to the floor. A review of the Care Plan titled; Activities of Daily Living (ADLs) dated 5/14/21 revised 5/15/22 documented interventions including Dependent Assistance of 2 staff for Bed Mobility. A review of the resident's C.N.A. Documentation Survey Report dated (MONTH) 22 documented to provide 'total assist of 2 staff for bed mobility'. On 11/02/22 at 2:40 PM, an interview was conducted with Licensed Practical Nurse (LPN #5), who stated the resident required 2 staff for bed mobility and 1 staff to assist for toilet use/check and change in bed. The LPN stated that means that 2 staff should provide assistance, the first person to wash and change the resident's brief and the second person should be on the other side of the bed to hold the resident on her side and keep the resident from rolling off the bed. The LPN stated that on 7/07/22, the T.N.A. called him/her to the room and s/he saw the resident lying on the floor with a bleeding head injury bleeding from the top right side of the forehead. The (MI)P.N. stated that the T.N.A. stated s/he had provided care to turn and position the resident without assistance and the resident slipped off the bed. The LPN stated s/he didn't verbally tell the TNA that the resident required 2 staff for bed mobility when the LPN gave the TNA their assignment, for the reason that the TNA had cared for the resident in the past and the resident had not had any changes to her plan of care. The LPN stated that s/he had recently spoken with all the C.N.A.s and T.N.A.s regarding the importance of using 2 staff for assistance when required, but not specifically for that resident. On 11/02/22 at 3:45 PM, an interview was conducted with the Temporary Nursing Assistant T.N.A. (TNA) who stated s/he had cared for the resident previously and had always cared for the resident without assistance. The TNA stated s/he did not know that the resident required 2 staff for bed mobility. The TNA stated the Kardex was confusing because it said the resident required 1 staff for toilet use. The TNA stated that s/he did not look at the instructions in the Kardex. The TNA stated that the other C.N.A.s gave him/her instructions to provide assistance to the resident without another staff to assist. The TNA stated that when s/he got his/her assignment, the nurse did not explain that the resident required 2 staff for bed mobility. On 11/02/22 at 2:35 PM, an interview was conducted with Registered Nurse Unit Manager (RNUM#3), who stated s/he was the RNUM on the second floor unit and they called from the second-floor unit to assess the resident on the third floor. The RNUM stated s/he found the resident on the floor to the left side of the bed, lying on her left side. The resident was bleeding from a small laceration about 1 cm to the left forehead, and s/he applied a pressure dressing and ice to the affected area. The RNUM stated s/he completed a full assessment and reported to the Director of Nursing, told the Physician, wrote the assessment note and took orders to transfer the resident to the hospital. The RNUM stated that the TNA stated s/he provided care to the resident without any other staff to assist. The RNUM stated s/he asked the T.N.A., if s/he was aware that the resident required 2 staff to assist with bed mobility and the TNA didn't seem to know, although the TNA had cared for the resident in the past. The RNUM told the TNA that the resident doesn't move in the bed without assistance and requires 2 staff for turning and positioning in bed. The RNUM stated it is the TNA's responsibility to check the Kardex prior to cares and the LPN on the unit is responsible for the TNA's and C.N.A.s on the unit. The RNUM stated that the nurse who makes the assignment gives report to any new staff and of any changes to the residents. On 11/15/22 at 2:00PM, an interview was conducted with the previous Director of Nursing who was the DON at the time of the incident (Previous DON) who stated that the RNUM on the 2nd floor was responsible for any assistance the 3rd floor unit required from a Registered Nurse and the LPN was responsible for the TNAs and CNAs on the unit. The previous DON stated the resident was dependent on 2 staff for bed mobility and did not participate in bed mobility. The previous DON stated that the resident's bed grab bars had been previously removes on 7/1/22 due to a decline in bed mobility, but the resident had required 2 staff assistance with bed mobility prior to that date On 11/15/22 at 2:15 PM, an interview was conducted with the Physician who stated the resident was dependent for all care and required 2-person assistance for care. The Physician stated the resident did not participate in bed mobility and had some contractures of the hands and wrists. 415. 11 (c) (1) | Plan of Correction: ApprovedMarch 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-600 I. The following actions were accomplished for the residents identified in the sample: Resident #1 Resident #1 was hosptalized on [DATE] and remains in the hospital. If the resident is discharged back to the facility, the IDCPT will develop a care plan that addresses the resident's risk of abusing other residents and to be abused with resident-specific care plan interventions. The facility has determined that the resident may require one-to-one supervision when he returns to the facility, but a determination will be made on his return. Resident #2 The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/24/2024 following the resident-to-resident sexual abuse incident and no complaints were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the resident's risk to be abused. On 3/26/2025 the IDCP Team completed an additional review of the resident's risk to be abused care plan and updated it to include person centered interventions based on the resident's involvement with family and interest in recreational activities including -- - Provide the resident with a cup of coffee and home magazines to flip through - Weekly rosary program - Utilize catholic prayers (Hail (NAME) and Our Father to calm the resident) - Music programs with emphasis on show tunes (favorite music) - Resident was removed from the early get up list, by preference (hx of combative behavior during caregiving ) The resident has not been involved in any negative peer to peer interaction since 12/16/ 24. Resident #3 The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/17/2024 following the resident-to-resident sexual abuse incident and no issues were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the resident's risk to be abused. On 03/26/2025 the IDCP Team completed an additional review of the resident's potential for abuse care plan and added additional person-centered interventions including -- - provide opportunities to watch old movies with her peers - play music of preference i.e. Sinatra, Dean Martin, Perry Como - participation in Busy Bees table to engage in diversional activity- ensure game is provided to the resident first, as per preference and history of grabbing items from others The resident has not been involved in any negative peer to peer interactions since 12/16/ 25. Resident #4 The resident was seen by the social worker on 2/24/2025 and had no recollection of the incident that occurred on 2/22/ 2025. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 02/24/2025 following the resident-to-resident sexual abuse incident and no distress was identified at that time. The resident had been followed by psychiatry and psychology since readmission on 5/14/2024 related to her behaviors/ [DIAGNOSES REDACTED]. depression. She continues to be followed by both services and is closely monitored related to ongoing behaviors i.e. refusals of care, wandering, flirtatiousness comments, verbal outbursts. The resident is currently on 30- minute checks related to her behaviors. [MEDICAL CONDITION] medications inclusive of [MEDICATION NAME] sprinkles, duloxetine, [MEDICATION NAME] and trazadone continue to be part of the resident's treatment plan. The IDCP Team updated the plan of care on 02/24/2024 to address the resident's risk of being abused. On 03/26/2025 the IDCP Team completed an additional review of the resident's risk of being abused. The care plan was updated to include -- - if resident is upset and/or agitated call nephew or cousin to allow resident to speak with them - offer activities of specific resident interest i.e. Good Housekeeping magazines, cards, casino games - Utilize soda and sweet snacks to divert from undesirable comments/behaviors (resident preference) - if resident refuses care, provide time and space and reapproach The resident has not been involved in any negative peer to peer interactions since 02/22/ 2025. On 03/05/2025, the facility developed and implemented a plan for Abuse Prevention education related to the immediate jeopardy situation to ensure all staff received this education prior to the start of their next assigned shift. 89% of staff on duty completed the education by 03/07/ 2025. This education continued through 03/25/ 2025. 100% compliance was met by all departments, other than nursing, which has a compliance rate of 96%. Directed In-service is scheduled to be initiated on 04/01/ 2025. II. The facility was notified of the immediate jeopardy situation on 03/05/2025 and implemented the following: The facility convened a QAPI meeting on 03/06/2025 to discuss the root cause of the abuse situation Administration initiated staff training on the following topics on 03/06/2025 -- o Reporting process o How to report Abuse, Neglect and Mistreatment o Unit Behavior Management meeting o 1:1 observation and 30-minute monitoring o Role of the RN Supervisor regarding reporting abuse, neglect and mistreatment o Safeguarding residents with cognitive impairments against sexual and/ or inappropriate behaviors II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Please refer to corrective actions outlined at Sections II, III and IV of this DP(NAME). The CNO reviewed all Incident Reports for the period of 01/ 5 to 03/25/2025 and no additional events of abuse have occurred. The DNS/designee will continue to review all new Incident Reports daily to ensure prompt follow-up is completed for any type of abuse report. The facility's QAPI Committee and outside consultant participated in a DP(NAME) QAPI meeting on 03/25/2025, to discuss the issues identified at F-600 and conducted a Root Cause Analysis. During this meeting, the outside consultant provided education to the Committee members on Abuse Prevention principles and how non-adherence to abuse prevention practices, including management of resident sexual behaviors, can result in deficient practices such as those cited in the SOD. Education also addresses use of a Root Cause Analysis when compliance issues are identified All resident care plans related to abuse risk, at risk to be a victim or to victimize, requiring behavior management or other interventions to prevent are being reviewed by the IDCPT and updated, as necessary, to address the resident's current needs and problems and to ensure preventative measures are in place. If a care plan indicating potential risk to be a victim or to victimize has not been developed, one will be initiated, for all identified at risk residents. Nurse Managers will review the plan of care with the unit staff responsible and update the care plan and Kiosk as indicated. Effective 04/01/2025 through 04/03/2025, education will be provided by the outside consultant to all facility staff on the facility's Abuse Prohibition protocols including behavior management principles for residents at risk to abuse and those at risk of being abused. The education will include types of abuse; need for identification and monitoring of resident behaviors that may result in a potential abuse situation for another resident and staff response to behavioral symptoms with appropriate interventions to prevent abuse from reoccurring. This education will continue to be provided until all facility staff receive this mandatory education. III. The following system changes will be implemented to ensure continuing compliance with regulations: The CEO/Administrator, Medical Director and CNO and outside consultant reviewed and revised, as needed, the facility's policy on Abuse Prohibition Protocols to ensure that it addressed monitoring of resident behaviors that may provoke a reaction by staff, residents or others or create potential situations of abuse and protocols to manage such behaviors. The policy was revised to include the utilization of unit based behavioral management meetings to utilize in the identification and management of challenging and/or inappropriate behaviors On 03/25/2025, the CEO/Administrator, Medical Director, CNO and outside consultant reviewed and revised, as needed, the facility's policy on Resident Supervision Protocols. The policy was revised to include the use of 1:1 supervision and 30 minute checks to closely monitor a resident to ensure their safety and well-being, often due to behavioral, medical or cognitive concerns. On 03/25/2025 CEO/Administrator, Medical Director, CNO and outside consultant reviewed and revised the facility protocols for behavior management interventions related to managing a resident's risk factors to abuse others or to be abused. This protocol includes identifying resident-specific risk factors to abuse or be abuse and interventions to implement to prevent resident-to-resident abuse, including sexual abuse. Abuse Prevention education will continue to be provided by the Staff Educator/designee during orientation, annually and on an as needed basis, including following any resident reported abuse events. The Director of Social Work will follow up on all complaints voiced by a resident and / or family member regarding any allegation of abuse The Director of Nursing and RN Supervisors will monitor for compliance during random and routine monitoring rounds and observations on the Nursing Units and medical record review. Immediate corrective actions, such as re-education or reevaluation of a resident's plan of care regarding the potential to abuse or be abused, will be implemented as indicated. IV. The facility's compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QAPI Committee meeting co-chaired by an outside consultant was convened on 03/25/2025 to examine this deficiency. The facility will develop an audit tool to monitor and evaluate staff knowledge and understanding of the facility Abuse Prohibition Protocol and responsibilities in monitoring of resident behaviors that may result in a potential situation of abuse if appropriate preventative actions are not implemented. The Staff Educator will audit twenty-five staff members for staff knowledge and understanding of Prevention of Abuse, Neglect and Mistreatment and Reporting Protocols monthly for the next six months and then on a quarterly basis for the next two quarters. The sample will include staff from all disciplines. Corrective actions such as reeducation will be implemented when indicated. The compliance for staff knowledge threshold will be 95%. If the compliance threshold is not met at the end of the first 6-month period monthly auditing will continue as well as additional staff education provided. Monthly auditing will continue until a compliance threshold of 95% is reached. Audit findings will be reported to the QAPI Committee monthly for the next six months and then quarterly for the next two quarters for evaluation and follow-up. At the end of this period, the Committee will determine the need for ongoing monitoring and at what frequency. The facility will develop an audit tool to monitor compliance with Abuse Prevention protocols to ensure documentation addressed resident-specific risk factors and interventions DNS/designee will audit twenty-five resident care plans related to Abuse Risk and Behavior Management monthly for the next six months and then quarterly for the next two quarters. Residents who exhibit sexual behaviors will be included in the survey sample. Corrective actions such as reeducation and / or updating of the plan of care will be implemented when indicated. The compliance threshold will be 95%. If the compliance threshold is not met at the end of the first 6-month period monthly auditing of at risk for abuse or to be abused care plans will continue monthly with additional staff education provided. Monthly auditing will continue until a compliance threshold of 95% is reached. All Abuse Risk and Behavior Management audit findings will be reported to the QAPI Committee monthly for the next six months and then quarterly for evaluation and follow-up. The CNO/designee will continue to report all Abuse, Neglect and Mistreatment allegations and investigation findings to the QAPI Committee on an ongoing basis for evaluation, discussion and implementation of system changes to assist with the Prevention of Abuse, Neglect and Mistreatment. The CNO/designee will continue to review all reported allegations of abuse and make a report to the NYSDOH as per requirements. Responsibility: Chief Nursing Officer Completion Date: 4/17/2025 |