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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: December 20, 2023
Corrected date: February 14, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY 617), the facility failed to ensure that two allegations of sexual abuse were investigated. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. This resulted in Immediate Jeopardy for Resident #1 and Resident #2 and a potential to affect 104 other facility residents. The findings are: The facility's undated policy titled. Abuse Prevention documented under the Reporting portion of the policy and reads in part: Reporting- All employees are required to immediately report any information which leads them to believe abuse has occurred. Reports can be made to chain of command: to the nurse, a supervisor, department head, Social Services, Nursing Administration, Administration, or to the New York State Department of Health. The policy did not address the reporting timeframe and the requirement to inform the local law enforcement of any allegations of abuse. 1) Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. A grievance report dated 12/07/2023 documented that on 12/2/2023 that Resident #1's family reported to Social Worker #2 that Resident #1 told them that someone molested (to make unwanted or improper sexual advances towards someone) Resident #1 the night of 12/1/2023. There was no documented evidence that the facility investigated the reported sexual abuse. During an interview on 12/20/2023 at 11:41 A.M., Certified Occupational Therapist Assistant #1 stated?Resident #1 told them on 12/02/2023 that Certified Nursing Assistant #1 asked Resident #1 to remove their clothes to play a game and inappropriately touched them the day before. Certified Occupational Therapist Assistant #1 stated they reported the allegations to a nursing staff member (could not recall the name). Certified Occupational Therapist Assistant #1 stated they did not document the allegations in the residents' records. During an interview on 12/21/2023 at 11:07 AM with Resident #1,?they stated that a male staff member was in their room and told them to take off their clothes so they could play a game. Resident #1 was crying during the interview.? Resident #1 stated they did not recall the name of the staff member. The resident was unable to give any further description of the alleged perpetrator or further account of their encounter with the alleged perpetrator. During an interview with Social Worker #2 on 12/21/2023 at 1:01 PM, they stated someone (did not recall the name and date) from the rehabilitation department told them that Resident #1 reported that a Certified Nursing Assistant (did not give a specific name) told Resident #1 to take off their clothes and do a dance. Social Worker #2 stated they interviewed Resident #1 on 12/07/2023 with Resident #1's family present. Social Worker #2 stated that Resident #1 was confused at the time of the interview and did not have a recollection of the alleged abuse. Social Worker #2 stated Resident #1's family told them that Resident #1 identified Certified Nursing Assistant #1 as the individual who had the alleged encounter with Resident #1. Social Worker #2 stated they reported the sexual abuse allegation to Social Worker #1. During an interview with Social Worker #1 on 12/22/2023 at 12:13 PM they stated they became aware of an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant #1 on 12/07/2023. Social Worker #1 was made aware of the allegation by Social Worker #2. Social Worker #1 stated they interviewed Resident #1 about the sexual abuse allegation but Resident #1 was confused and was not able to disclose any information about the alleged abuse. Social Worker #1 stated they were unsuccessful at getting any information from Resident #1 hence they did not do anything further. Social Worker #1 stated they were in-serviced on abuse in the past. Social Worker #1 stated they documented on the grievance report and informed the Director of Nursing on 12/8/2023. During an interview on 12/21/2023 at 11:05 AM, Registered Nurse #1 stated that they became aware that an allegation was made by Resident #1 that Certified Nursing Assistant #1 told Resident #1 to take off their clothes to do a dance. Registered Nurse #1 stated they could not recall the date they became aware or how they became aware. Registered Nurse #1 stated they did not assess Resident #1 after being informed of the allegation because they did not think it was necessary. Registered Nurse #1 stated they did not document the allegation in the resident's medical record or the nurses' daily report. Registered Nurse #1 stated they did not report the allegation to anyone because they were aware the allegation was being investigated by the social worker. During an interview on 12/22/2023 at 10:03 AM, Registered Nurse #2 stated that Social Worker #2 told them on 12/6/2023 of an allegation of sexual abuse. Registered Nurse #2 stated that Certified Nursing Assistant #1 asked Resident #1 to take off their gown and dance. Registered Nurse #2 stated they did not do an assessment on Resident#1 after they were made aware of the allegation. Registered Nurse #2 stated they believed that Social Worker #1 initiated an investigation related to the sexual abuse allegation. Registered Nurse #2 stated they notified the Director of Nursing of the alleged abuse?via an e-mail on 12/06/2023. ? During an interview with the Director of Nursing on 12/22/2023 at 11:02 AM they stated they received an e-mail on 12/06/2023 from Registered Nurse #2 informing them that Certified Nursing Assistant #1 should no longer be assigned to Resident #1. The Director of Nursing stated the e-mail from Registered Nurse #2 did not allege abuse and that the e-mail only documented removing Certified Nursing Assistant #1 from Resident #1's assignment. The Director of Nursing further stated on 12/08/2023 that they were informed of a grievance report regarding an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant #1. The Director of Nursing stated they did not do an investigation because they were out sick and thought that the incident was already investigation. During an interview on 12/22/2023 at 11:36 AM with the Administrator, they stated they were aware of a grievance report alleging sexual abuse reported by Resident #1 involving Certified Nursing Assistant #1. The Administrator did not recall the date they became aware of the allegation. The Administrator stated that an investigation was not initiated because they believed it was sexual abuse discrimination against Certified Nursing Assistant #1. The Administrator further stated that Certified Nursing Assistant #1 was not suspended and continued to perform their regular duties. The Administrator stated that Certified Nursing Assistant #1 was removed from Resident #1's assignment. During an interview on 12/22/2023 at 3:36 PM Certified Nursing Assistant #1 stated they were interviewed about the allegation made by Resident #1, however, they did not recall who interviewed them or the date of the interview. Certified Nursing Assistant #1 stated they were told they could not care for Resident #1. Certified Nursing Assistant #1 stated they were not suspended or re-educated on abuse and denied the allegation. 2) Resident #2 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The assessment indicated Resident #2 was independent with some activities of daily living and required supervision and setup with others. A grievance report dated 12/06/2023 documented that Social Worker #1 and Social Worker #2 were informed (the grievance did not identify the informant) that Resident #2 reported to the social workers today 12/06/2023 that Certified Nursing Assistant #1 touched Resident #2's leg and called them baby. It further documented that Resident #2 reported to the social workers that two weeks earlier, Certified Nursing Assistant #1 invited them out to dinner in New York City which made Resident #2 uncomfortable. The Grievance documented that Social Worker #1 and Social Worker #2 spoke with Registered Nurse #1 and Nursing Supervisor #2 and requested Certified Nursing Assistant #1 not be assigned to Resident #2.? There was no documented evidence in Resident #2's medical record of the sexual abuse allegation. During an interview with Resident #2 on 12/21/2023 at 10:27 AM, Resident #2 stated they are independent with most activities of daily living. Resident #2 stated Certified Nursing Assistant #1 approached Resident #2 while the resident was in their bed filing their nail. Resident #2 stated Certified Nursing Assistant #1 sat next to them on their bed, and then placed their hand on Resident #2's inner thigh and rubbed on it. Resident #2 described the touch as unwelcomed, uncomfortable, and scary. Resident #2 was upset and crying during the interview. Resident #2 stated Certified Nursing Assistant #1 also invited Resident #2 out to dinner in the city. Resident #2 stated they informed a staff member that they do not want Certified Nursing Assistant #1 to care for them any longer. Resident #2 stated they feel unsafe because they see Certified Nursing Assistant #1 all the time. Resident #1 stated the facility's social workers did not provide any emotional support.??? ?? During an interview on 12/21/2023 at 11:05 AM, Registered Nurse #1 stated that they became aware that an allegation was made by Resident #2 that Certified Nursing Assistant #1 inappropriately touched Resident #2's thigh. Registered Nurse #1 stated they could not recall the date they became aware or how they became aware. Registered Nurse #1 stated they did not assess Resident #2 after being informed of the allegation because they did not think it was necessary. Registered Nurse #1 stated they did not document the allegation in the resident's medical record or the nurses' daily report. Registered Nurse #1 stated they did not report the allegation to anyone because they believed the allegation was being investigated by the social worker. ? During an interview with Social Worker #2 on 12/21/2023 at 1:01 PM, they stated someone (did not recall the name and date) from the rehabilitation department told them that Resident #2 reported that Certified Nursing Assistant #1 touched Resident #2's thigh and made them uncomfortable and scared. Social worker #2 stated that they interviewed Resident #2 on 12/06/2023. Resident #2 reiterated the sexual abuse allegation to Social Worked #2. Social Worker #2 stated they documented Resident #2's sexual abuse allegation on the grievance paperwork and placed it in the Director of Nursing Box (did not recall the date of placement). Social Worker #2 stated that they observed Resident #2 in the facility's hallway on 12/07/2023 and Resident #2 appeared to be fine. Social Worker #2 stated they did not offer any social services to Resident #2 because the resident appeared fine.? During an interview on 12/22/2023 at 10:03 AM, Registered Nurse #2 stated that Social Worker #2 told them of the allegation of sexual abuse to Resident #2. Registered Nurse #2 stated that Certified nursing Assistant #1 was inappropriately rubbing Resident #2's inner thigh. Register Nurse #2 stated they did not assess Resident #2 because the alleged encounter between Resident #2 and Certified Nursing Assistant #1 happened several days prior (cannot recall date). Registered Nurse #2 stated they relied on the social worker to assess the residents and investigate the sexual abuse allegation. Registered Nurse #2 stated they notified the Director of Nursing of the alleged abuse via an e-mail on 12/06/2023. During an interview with the Director of Nursing on 12/22/2023 at 11:02 AM they stated they received an e-mail on 12/06/2023 from Registered Nurse #2 informing them that Certified Nursing Assistant #1 should no longer be assigned to Resident #2. The Director of Nursing stated the e-mail from Registered Nurse #2 did not allege abuse, that the e-mail documented that Certified Nursing Assistant #1 was removed from Resident #1's assignment and that social service was involved. The Director of Nursing further stated on 12/08/2023 that they were informed of a grievance report regarding an allegation of sexual abuse made by Resident #2 involving Certified Nursing Assistant #1. The Director of Nursing stated they did not investigate the sexual abuse allegations because they were out sick and thought it was already investigated. During interview on 12/22/23 at 11:36 AM with the Administrator they stated they were aware of a grievance report alleging sexual abuse reported by Resident #2 involving Certified Nursing Assistant #1. The Administrator did not recall the date they became aware. The Administrator stated they did not investigate the sexual allegation abuse because they believed it was discrimination against Certified Nurse Assistant #1. The Administrator further stated that Certified Nurse Assistant #1 was not suspended and continued to perform their regular duties. The Administrator stated that Certified Nurse Assistant #1 was removed from Resident #2's assignment. During an interview with Social Worker #1 on 12/22/2023 at 12:13 PM they stated they became aware of an allegation of sexual abuse made by Resident #2 involving Certified Nursing Assistant #1 on 12/06/2023. Social Worker #1 stated they interviewed Resident #2 and the resident stated that Certified Nursing Assistant #1 asked them out to dinner and called Resident #2 baby. The resident also stated that Certified Nursing Assistant # 1 proceeded to touch their (Resident #2's) thigh while they (Resident #2) were sitting on their bed. Resident #2 requested that Certified Nursing Assistant #1 no longer provide care to them. Social Worker #1 stated that they documented the allegation of sexual abuse on a grievance report and informed the Director of Nursing. Social Worker #1 did not go any further with the allegation because they (Social Worker #1) felt it was not sexual abuse. Social Worker #1 stated that calling a resident baby and asking them to dinner was inappropriate. Social Work #1 also stated that Resident #2 requested to remove Certified Nursing Assistant #1 from their care. Social Worker #1 also stated that they were in-serviced on abuse in the past (not sure of the date). During an interview on 12/22/2023 at 3:36 PM Certified Nursing Assistant #1 stated they were interviewed about the allegation reported by Resident #2, however they did not recall who interviewed them or the date of the interview. Certified Nursing Assistant #1 stated they were told they could not care for Resident #2 going forward and they were not suspended or re-educated on abuse. During an interview with the Medical Director on 01/03/2024 at 1:15 PM, the Medical Director stated they were not aware of the sexual abuse allegations involving Resident #1 or Resident #2. Medical Director stated they became aware the evening of 12/22/2023 when the facility was in Immediate Jeopardy. The Medical Director stated that the facility should have investigated the sexual abuse allegation. 10NYCRR 415.4 (b) (3) | Plan of Correction: ApprovedJanuary 19, 2024 F- 610 Investigate/Prevent/Correct Alleged Violation I. The following actions were accomplished for the residents identified in the sample: Resident #1 An incident report was initiated by the DON on 12/22/2023 and an investigation was completed on 1/5/24 regarding the abuse allegation reported by a family member. The Administrator reported the allegation of abuse to the NYSDOH, local police and the Attorney General's Office on 12/22/2023. An incident report was initiated on 12/26/2023 based on additional information provided by the resident regarding sexual misconduct. The facility reported this new allegation of abuse to the NYSDOH, local police and Attorney General's Office on 12/26/2023 related to additional information provided by the resident. On 12/27/2023 the Administrator/designee counseled and reeducated Certified Occupational Therapist Assistant #1, who initially was informed by Resident #1 of the alleged abuse, on her responsibilities related to abuse prevention and reporting any allegation of abuse that she has knowledge of promptly and if action not taken to report to another administrative staff member. Resident #2 An incident report was initiated on 12/22/2023 by the DON and an investigation was completed on 01/05/2024 regarding the allegation. The DON reported the allegation of abuse to NYSDOH, local police and the Attorney General's Office on 12/22/2023. Resident #1 & Resident #2 CNA #1 was suspended on 12/22/2023 and remains off duty. On 12/27/2023, the Administrator/designee counseled and reeducated Social Workers #1 & #2 regarding the facility?ÇÖs Abuse Prevention, Reporting and Investigation protocols to follow when an allegation of abuse is made so that protecting the resident, reporting per mandated timeframes, timely investigating and other necessary actions can be implemented. This reeducation for Social Worker #1 reinforced their responsibility to follow-up with the Administrator if a report to the DNS is not promptly acted on as well as reinforcing timely reporting so that required notifications can be made to the NYSDOH and local law enforcement. On 01/04/2024, Registered Nurse #1, Registered Nurse #2 & RN Supervisor #2 were counseled and reeducated by the Acting DON regarding the facility?ÇÖs Abuse Prevention, Reporting and Investigating protocols, including protocols for promptly reporting all abuse allegations to Administration for prompt follow-up reporting and investigating. This reeducation reinforced the RN?ÇÖs responsibility to assess the resident following an abuse allegation and documenting such an assessment in the medical record as well as protecting a resident who voiced an allegation of abuse by removing the identified staff member from duty until an investigation is completed. The Administrator provided counselling and reeducation to the Director of Nursing, who was in the DON position when the allegations of abuse were made, regarding the importance of timely reporting all alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and reporting abuse allegation to the proper authorities, including law enforcement and the NYSDOH, within prescribed timeframes and responsibility for conducting a comprehensive investigation so that needed corrective actions can be implemented. On 01/03/2024 the Administrator identified the ADON/MDS Coordinator as the Acting Director of Nursing, and the prior Director was assigned other duties. On 12/22/2023 the facility?ÇÖs Abuse Prevention Policy was reviewed and revised to include information regarding the 2-hr. timeframe for reporting an allegation of abuse and notifying local law enforcement of any allegation of abuse. Education was initiated by the inservice coordinator with all staff related to abuse prevention, investigation and reporting on 12/22/2023 and approximately 95% compliance was met as of 12/30/23. An outside consultant was hired to provide assistance and was onsite on 01/02/2024 01/03/2024 & 01/04/2024. The Abuse Prevention, Investigation and Reporting Policy was reviewed and revised again on 01/03/2024 with the assistance of the outside consultant to comply with NYS and Federal Regulations. The lesson plan for abuse prevention/reporting and investigations was revised on 01/02/2024 and the consultant provided additional staff education starting 01/02/2024. As of 01/03/2024 approximately 50% compliance was reached. An educational session was recorded for ongoing use by the facility. Education will continue until compliance is met for all staff. A post-test was developed to validate staff knowledge of the content of the material. A lesson plan was developed by the outside consultant for abuse investigation and reporting with content directed to administrative staff who have responsibility for investigation and reporting of resident incident/accidents. An education session was conducted by the outside consultant with Administrative and Nursing Supervisory staff on 01/02/2024. On 01/03/24, the outside consultant met with the Administrator to review their responsibilities for oversight of the facility?ÇÖs Abuse Prevention, Reporting and Investigation protocols, including reporting to the NYSDOH and local law enforcement per mandated timeframes. 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 practices. Between 01/03/2024 and 01/19/2024 all occurrence reports related to allegations of abuse, neglect, exploitation, or mistreatment from 09/01/2023 to present were reviewed by the Administrator and Acting Director of Nursing to determine if investigations were thoroughly completed, that a resident was protected during the investigation and that incidents that met NYSDOH reporting requirements were reported. No additional findings were noted; no additional reporting to the NYSDOH was necessary. The facility?ÇÖs QAPI Committee and Outside Consultant participated in a Direct Plan QAPI meeting on 01/18/2024, to discuss the deficiency findings identified at F-610 and conducted a Root Cause Analysis. Based on the Root Cause Analysis that was part of the DP(NAME) QAPI meeting on 01/18/2024, the following issues were identified that required corrective actions: ?Çó The facility?ÇÖs policy on Abuse would benefit from additional review. ?Çó The facility policy on Incident Reporting would benefit from review. ?Çó The facility policy on Investigations would benefit from review. ?Çó All HCPs would benefit from additional education related to incident/accident reporting and investigations inclusive of the steps to follow to communicate and respond to changes in a resident?ÇÖs condition/behavior. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). Effective 01/22/2024 education will be provided by the Outside Consultant to all facility staff on investigating all allegations of abuse, neglect and mistreatment, preventing further abuse neglect and mistreatment during the investigation and reporting the results of all investigations as per established protocols to the administrator and to other officials in accordance with Federal and State law. Education will include the importance of caregiver responsibilities related to prompt reporting of resident events including unusual behaviors so that follow-up can be completed for an event that may be indicative of abuse, neglect or mistreatment is promptly investigated including follow-up completed related to a change in condition. This education will continue to be provided until all facility and agency staff receive this mandatory education. III. The following system changes will be implemented to assure continuing compliance with regulations: On 01/22/2024, the outside consultant along with the Administrator and Acting Director of Nursing will conduct an additional review and revision of the policies and procedures related to Abuse Prevention Investigation and Reporting to ensure all requirements are included to ensure consistency with current Federal and State guidelines as stated in the State Operations Manual dated 10/24/2022. Effective 01/22/2024 the Director of Nursing/designee will monitor information related to resident occurrences inclusive of allegations of violations of abuse/crime reported to and/or identified by staff that are shared at Morning Report and documented in the 24-hour Report are immediately investigated and reported per regulatory requirements, as indicated, to ensure that no abuse/crime has occurred. Immediate corrective action, such as completing an Incident/Accident Report and associated investigation or protecting a resident during an investigation, providing staff reeducation, or reporting to the state agency within the required timeframe, will be implemented as needed. The Director of Nursing/designee will continue to review all occurrence reports and associated investigation documents to ensure a thorough investigation has been completed and a determination made regarding if an occurrence meets Federal and State reporting requirements. The Director of Nursing will be responsible for reporting all reportable events to the Administrator, the State Survey Agency, Local Law Enforcement or APS, to meet reporting requirements. IV. The facility?ÇÖs compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QA Committee meeting co-chaired by the Outside Consultant was convened on 01/18/2024 to examine this deficiency. The facility will develop an audit tool to monitor compliance with appropriate actions taken in response to alleged violations to ensure all alleged violations are thoroughly investigated, reports are made to the NYSDOH within 2-hrs., local law enforcement and other agencies are notified as per policy and requirements, effective measures/corrective actions implemented to prevent recurrence while the investigation is in process, and results of all investigation are reported to the Administrator/designee and to the State Survey Agency per mandated requirements. The DNS/designee will audit all Incident/Accident Reports and associated investigations monthly for the next 3 months and then quarterly. All alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries to an unknown source and misappropriation of resident property, or an event where there is a suspicion of a crime, will be included in the audit sample. All Incident/Accident Report and investigation audit findings will be reported to the Administrator monthly. Corrective actions, such as staff reeducation, submitting a required report or enhancing investigation documentation, will be implemented as needed. The Director of Nursing will report the Incident/Accident Report investigation audit findings to the QAPI Committee monthly for the next three months and then quarterly for discussion, evaluation, and follow-up corrective actions. Following this 3-month period, the Director of Nursing/designee will audit 25% of all Incident/Accident Reports and investigations quarterly. All resident allegations of any type of abuse will be included in the audit sample. All Incident/Accident Report and investigation audit findings will be reported to the Administrator monthly. The Director of Nursing will report all Incident/Accident Report and investigation audit findings to the QAPI Committee quarterly for evaluation, discussion and follow-up corrective actions. The Director of Nursing will continue to provide a Summary Report of all reported events to the QAPI Committee, minimally, on a quarterly basis for discussion and evaluation. Responsibility: _Administrator_ |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: December 20, 2023
Corrected date: February 14, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY 617), the facility failed to ensure that two allegations of sexual abuse were reported to the Department of Health and Local Law Enforcement within two hours. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. This resulted in Immediate Jeopardy for Resident #1 and Resident #2 and a potential to affect 104 other facility residents. The findings are: The facility's undated policy titled. Abuse Prevention documented under the Reporting portion of the policy and reads in part: Reporting- All employees are required to immediately report any information which leads them to believe abuse has occurred. Reports can be made to chain of command: to the nurse, a supervisor, department head, Social Services, Nursing Administration, Administration, or to the New York State Department of Health. The policy did not address the reporting timeframe and the requirement to inform the local law enforcement of any allegations of abuse. 1) Resident #1 was admitted with [DIAGNOSES REDACTED].The Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. A grievance report dated 12/07/2023 documented that on 12/2/2023 Resident #1's family reported to Social Worker #2 that Resident #1 told them that someone molested (to make unwanted or improper sexual advances towards someone) Resident #1 the night of 12/1/2023. There was no documented evidence that the facility reported the alleged abuse to the Local Law Enforcement or the New York State Department of Health. During an interview on 12/20/2023 at 11:41 A.M.,Certified Occupational Therapist Assistant #1 stated?Resident #1 told them on 12/02/2023 that Certified Nursing Assistant #1 asked Resident #1 to remove their clothes to play a game and inappropiately touched them the day before. Certified Occupational Therapist Assistant #1 stated they reported the allegations to a nursing staff member (could not recall the name). Certified Occupational Therapist Assistant #1 stated they did not document the allegations in the residents' records. During an interview on 12/21/2023 at 11:07 AM with Resident #1,they stated that a male staff member was in their room and told them to take off their clothes so they could play a game. Resident #1 was crying during the interview. Resident #1 stated they did not recall the name of the staff member. The resident was unable to give any further description of the alleged perpetrator or further account of their encounter with the alleged perpetrator. During an interview with Social Worker #2 on 12/21/2023 at 1:01 PM, they stated someone (did not recall the name and date) from the rehabilitation department told them that Resident #1 reported that a Certified Nursing Assistant (did not give a specific name) told Resident #1 to take off their clothes and do a dance. Social Worker #2 stated they interviewed Resident #1 on 12/07/2023 with Resident #1's family present. Social Worker #2 stated that Resident #1 was confused at the time of the interview and did not have a recollection of the alleged abuse. Social Worker #2 stated Resident #1's family told them that Resident #1 identified Certified Nursing Assistant #1 as the individual who had the alleged encounter with Resident #1. Social Worker #2 stated they reported the sexual abuse allegation to Social Worker #1. During an interview with Social Worker #1 on 12/22/2023 at 12:13 PM they stated they became aware of an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant #1 on 12/07/2023. Social Worker #1 was made aware of the allegation by Social Worker #2. Social Worker #1 stated they interviewed Resident #1 about the sexual abuse allegation but Resident #1 was confused and was not able to disclose any information about the alleged abuse. Social Worker #1 stated they were unsuccessful at getting any information from Resident #1 hence they did not do anything further. Social Worker #1 stated they were in-serviced on abuse in the past. Social Worker #1 stated they documented on the grievance report and informed the Director of Nursing on 12/8/2023. During an interview on 12/21/2023 at 11:05 AM, Registered Nurse #1 stated they became aware an allegation was made by Resident #1 against Certified Nurse Assistant #1, where in Certified Nursing Assistant #1 told Resident #1 to take off their clothes to do a dance. Registered Nurse #1 stated they could not recall the date they became aware or how they became aware. Registered Nurse #1 stated they did not assess Resident #1 after being informed of the allegation because they did not think it was necessary. Registered Nurse #1 stated they did not document the allegation in the resident's medical record or the nurses' daily report. Registered Nurse #1 stated they did not report the allegation to anyone because they were aware the allegation was being investigated by the social worker. During an interview on 12/22/2023 at 10:03 AM, Registered Nurse #2 stated that Social Worker #2 told them on 12/6/2023 of an allegation of sexual abuse. Registered Nurse #2 stated that Certified Nursing Assistant #1 asked Resident #1 to take off their gown and dance. Registered Nurse #2 stated they did not do an assessment on Resident#1 after they were made aware of the allegation. Registered Nurse #2 stated they believed that Social Worker #1 initiated an investigation related to the sexual abuse allegation. Registered Nurse #2 stated they notified the Director of Nursing of the alleged abuse via an e-mail on 12/06/2023. During an interview with the Director of Nursing on 12/22/2023 at 11:02 AM they stated they received an e-mail on 12/06/2023 from Registered Nurse #2 informing them that Certified Nursing Assistant #1 should no longer be assigned to Resident #1. The Director of Nursing stated the e-mail from Registered Nurse #2 did not allege abuse and that the e-mail only documented removing Certified Nursing Assistant #1 from Resident #1's assignment. The Director of Nursing further stated on 12/08/2023 they were informed of a grievance report regarding an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant #1. The Director of Nursing stated they did not report the sexual abuse allegations to Local Law Enforcement or the New York State Department of Health because they were out sick and thought that the incident was already reported. During an interview on 12/22/2023 at 11:36 AM with the Administrator, they stated they were aware of a grievance report alleging sexual abuse reported by Resident #1 involving Certified Nursing Assistant #1. The Administrator did not recall the date they became aware of the allegation. The Administrator stated they did not report the allegation to the Local Law Enforcement or the Attorney General because they believed it was sexual abuse discrimination against Certified Nursing Assistant #1. The Administrator further stated that Certified Nursing Assistant #1 was not suspended and continued to perform their regular duties. The Administrator stated that Certified Nursing Assistant #1 was removed from Resident #1's assignment. During an interview on 12/22/2023 at 3:36 PM Certified Nursing Assistant #1 stated they were interviewed about the allegation made by Resident #1, however, they did not recall who interviewed them or the date of the interview. Certified Nursing Assistant #1 stated they were told they could not care for Resident #1. Certified Nursing Assistant #1 stated they were not suspended or re-educated on abuse and denied the allegation. 2) Resident #2 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The assessment indicated Resident #2 was independent with some activities of daily living and required supervision and setup with others. A grievance report dated 12/06/2023 documented that Social Worker #1 and Social Worker #2 were informed (the grievance did not identify the informant) that Resident #2 reported to the social workers today 12/06 that Certified Nursing Assistant #1 touched Resident #2's leg and called them baby. It further documented that Resident #2 reported to the social workers that two weeks earlier, Certified Nursing Assistant #1 invited them out to dinner in New York City which made Resident #2 uncomfortable. The Grievance documented that Social Worker #1 and Social Worker #2 spoke with Registered Nurse #1 and Nursing Supervisor #2 and requested Certified Nursing Assistant #1 not be assigned to Resident #2. There was no documented evidence in Resident #2's medical record of the sexual abuse allegation. There was no documented evidence that the facility reported the allegation to the Local Law Enforcement or the New York State Department of Health. During an interview with Resident #2 on 12/21/2023 at 10:27 AM, Resident #2 stated they are independent with most activities of daily living. Resident #2 stated Certified Nursing Assistant #1 approached Resident #2 while the resident was on their bed filing their nail. Resident #2 stated Certified Nursing Assistant #1 sat next to them on their bed, and then placed their hand on Resident #2's inner thigh and rubbed on it. Resident #2 described the touch as unwelcomed, uncomfortable, and scary. Resident #2 was crying during the interview. Resident #2 stated Certified Nursing Assistant #1 also invited Resident #2 out to dinner in the city. Resident #2 stated they informed a staff member that they do not want Certified Nursing Assistant #1 to care for them any longer. Resident #2 stated they feel unsafe because they see Certified Nursing Assistant #1 all the time. Resident #1 stated the facility's social workers did not provide any emotional support. During an interview on 12/21/2023 at 11:05 AM, Registered Nurse #1 stated that they became aware that an allegation was made by Resident #2 that Certified Nursing Assistant #1 inappropriately touched Resident #2's thigh. Registered Nurse #1 stated they could not recall the date they became aware or how they became aware. Registered Nurse #1 stated they did not assess Resident #2 after being informed of the allegation because they did not think it was necessary. Registered Nurse #1 stated they did not document the allegation in the resident's medical record or the nurses' daily report. Registered Nurse #1 stated they did not report the allegation to anyone because they were aware the allegation was being investigated by the social worker. During an interview with Social Worker #2 on 12/21/2023 at 1:01 PM, they stated someone (did not recall the name and date) from the rehabilitation department told them that Resident #2 reported that Certified Nursing Asistant #1 touched Resident #2's thigh and made them uncomfortable and scared. Social worker #2 stated that they interviewed Resident #2 on 12/06/2023. Resident #2 reiterated the sexual abuse allegation to Social Worked #2. Social Worker #2 stated they documented Resident #2's sexual abuse allegation on the grievance paperwork and placed it in the Director of Nursing Box (did not recall the date of placement). Social Worker #2 stated that they observed Resident #2 in the facility's hallway on 12/07/2023 and Resident #2 appeared to be fine. Social Worker #2 stated they did not offer any social services to Resident #2 because the resident appeared fine. During an interview on 12/22/2023 at 10:03 AM, Registered Nurse #2 stated that Social Worker #2 told them of the allegation of sexual abuse to Resident #2. Registered Nurse #2 stated Certified Nursing Assistant #1 was inapprpropriately rubbing Resident #2 inner thigh. Registed Nurse stated #2 stated they did not assess Resident #2 because the alleged encounter between Resident #2 and Certified Nursing Assistant #1 happened several days prior (can not recall date). Registered Nurse #2 stated they relied on the social worker to assess the residents and investigate the sexual abuse allegation. Registered Nurse #2 stated they notified the Director of Nursing of the alleged abuse via an e-mail on 12/06/2023. During an interview with the Director of Nursing on 12/22/2023 at 11:02 AM they stated they received an email on 12/06/2023 from Registered Nurse #2 informing them that Certified Nursing Assistant #1 should no longer be assigned to Resident #2. The Director of Nursing stated the email from Registered Nurse #2 did not allege abuse, the email documented not having Certified Nursing Assistant #1 take care of Resident #1 for now and that social service was involved. The Director of Nursing further stated on 12/08/2023 that they were informed of a grievance report regarding an allegation of sexual abuse made by Resident #2 involving Certified Nursing Assistant #1. The Director of Nursing stated they did not report the sexual abuse allegations to Local Law Enforcement or the New York State Department of Health because they were out sick and thought it was already reported. During interview on 12/22/23 at 11:36 AM with the Administrator they stated they were aware of a grievance report alleging sexual abuse reported by Resident #2 involving Certified Nursing Assistant #1. The Administrator did not recall the date they became aware. The Administrator stated they did not report the allegation to the Local Law Enforcement or the Attorney General because they believed it was discrimination against Certified Nurse Assistant #1. The Administrator further stated that Certified Nursing Assistant #1 was not suspended and continued to perform their regular duties. The Administrator stated that Certified Nursing Assistant #1 was removed from Resident #2 assignment. During an interview with Social Worker #1 on 12/22/2023 at 12:13 PM they stated they became aware of an allegation of sexual abuse made by Resident #2 involving Certified Nursing Assistant #1 on 12/06/2023. Social Worker #1 stated they interviewed Resident #2 and the resident stated that Certified Nursing Assistant #1 asked them out to dinner and called Resident #2 baby. The resident also stated that Certified Nursing Assistant #1 proceeded to touch their (Resident #2's) thigh while they (Resident #2) were sitting on their bed. Resident #2 requested that Certified Nursing Assistant #1 no longer provide care to them. Social Worker #1 stated that they documented the allegation of sexual abuse on a grievance report and informed the Director of Nurses. Social Worker #1 did not go any further with the allegation because they (Social Worker #1) felt it was not sexual abuse. Social Worker #1 stated that calling a resident baby and asking them to dinner was inappropriate. Social Work #1 also stated that Resident #2 requested to remove Certified Nursing Assistant #1 from their care. Social Worker #1 also stated that they were in-serviced on abuse in the past (not sure of the date). During an interview on 12/22/2023 at 3:36 PM Certified Nursing Assistant #1 stated they were interviewed about the allegation reported by Resident #2, however they did not recall who interviewed them or the date of the interview. Certified Nursing Assistant #1 stated they were told they could not care for Resident #2 going forward and they were not suspended or re-educated on abuse. During an interview with the Medical Director on 01/03/2024 at 1:15 PM, the Medical Director stated they were not aware of the sexual abuse allegations involving Resident #1 or Resident #2. Medical Director stated they became aware the evening of 12/22/2023 when the facility was in Immediate Jeopardy. The Medical Director stated that the facility should have reported the sexual abuse allegations to the New York State Department of Health and to the Local Law Enforcement within two hours. 10 NYCRR 415.4(b)(2) | Plan of Correction: ApprovedJanuary 19, 2024 F- 609 I. The following actions were accomplished for the residents identified in the sample: Resident #1 An incident report was initiated by the DON on 12/22/2023 and an investigation was completed on 1/5/24 regarding the allegation. The DON reported the allegation of abuse to the NYSDOH, local police and the Attorney General's Office on 12/22/2023. A full body check was conducted on 12/22/2023 by the unit nurse. No visible injuries were identified. A CCP related to the resident being at At Risk for Abuse was initiated on 12/22/2023 by the IDCP Team. The IDCP Team rereviewed the ?Ç£At Risk for Abuse?Ç¥ care plan on 12/26/2023 and the interventions were revised. Resident was placed on 1 : 1 monitoring on 12/24/ and the intervention remains active as of 1/3/24. The need for ongoing 1:1 was reviewed at the CCP meeting and maintained until discharge home on 01/09/2024. A psychiatric consultation was conducted on 12/26/2023. No medication changes were recommended by the psychiatrist. A psychology consult was conducted on 12/26/2023. There were no findings of emotional distress documented in the psychology consult. An incident report was initiated on 12/26/2023 based on additional information provided by the resident regarding sexual misconduct. The facility reported this new allegation of abuse to the NYSDOH, local police and Attorney General's Office on 12/26/2023 related to additional information provided by the resident. Ongoing monitoring of resident's general mood, behaviors with focus on any changes in customary routine are documented when observed. Resident continues to be visited on a frequent basis by his Social Worker who is providing emotional support. The IDCP Team is encouraging the family to continue daily visitation. On 12/27/2023 the Administrator/designee counseled and reeducated Certified Occupational Therapist Assistant #1, who initially was informed by Resident #1 of the alleged abuse, on her responsibilities related to abuse prevention and reporting any allegation of abuse that she has knowledge of promptly and if action not taken to report to another administrative staff member. Resident #2 An incident report was initiated on 12/22/2023 by the DON and an investigation was completed on 1/5/24 regarding the allegation. The DON reported the allegation of abuse to NYSDOH, local police and the Attorney General's Office on 12/22/2023. A full body check was attempted on 12/22/2023 by the RN but was declined. A CCP related to the resident being at At Risk for Abuse and trauma was initiated on 12/22/2023 by the IDCP Team. The IDCP Team rereviewed the ?Ç£At Risk for Abuse?Ç¥ care plan on 12/22/2023 and the interventions were revised on12/26/2023. Resident was placed on 1:1 monitoring on 12/24/2023. The intervention was discontinued on 12/27/2023 per resident request. A psychiatric consult was conducted on 12/26/2023. There were no recommendations for medication. Psychotherapy sessions were recommended to continue and are active. Ongoing monitoring of the resident's general mood, behaviors with a focus on any changes in customary routine documented when observed. Resident continues to be visited on a frequent basis by her Social Worker who is providing emotional support. Resident #1 & Resident #2 CNA #1 was suspended on 12/22/2023 and remains off duty. If a decision is made for the CNA to return to work, he will be counseled and reeducated on the facility?ÇÖs Abuse Prevention protocol prior to returning to duty. On 12/27/2023 the Administrator/designee counseled and reeducated Social Workers #1 & #2 regarding the facility?ÇÖs Abuse Prevention, Reporting and Investigation protocols to follow when an allegation of abuse is made so that protecting the resident, reporting per mandated timeframes, timely investigating and other necessary actions can be implemented. This reeducation for Social Worker #1 reinforced their responsibility to follow-up with the Administrator if a report to the DNS is not promptly acted on as well as reinforcing timely reporting so that required notifications can be made to the NYSDOH and local law enforcement. On 12/27/2023, Registered Nurse #1, Registered Nurse #2 & Nursing Supervision #2 were counseled and reeducated by the Administrator/designee regarding the facility?ÇÖs Abuse Prevention, Reporting and Investigating protocols, including protocols for promptly reporting all abuse allegations to Administration for prompt follow-up reporting and investigating. This reeducation reinforced the RNs responsibility to assess the resident following an abuse allegation and documenting such an assessment in the medical record as well as protecting a resident who voiced an allegation of abuse by removing the identified staff member from duty until an investigation is completed. Licensed nurses completed full house body checks on 12/26/2023. No physical findings were identified and there were no verbal allegations of abuse by any additional residents. ?Ç£At Risk for Abuse?Ç¥ care plans were initiated for all residents on 12/26/2023. The Administrator provided counselling and reeducation to the Director of Nursing, who was in the DON position when the allegations of abuse were made, regarding the importance of reporting all alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and reporting abuse allegation to the proper authorities, including law enforcement and the NYSDOH, within prescribed timeframes. On 01/03/2024 the Administrator identified the ADON/MDS Coordinator as the Acting Director of Nursing, and the prior Director was assigned other duties. On 12/22/2023 the facility?ÇÖs Abuse Prevention Policy was reviewed and revised to include information regarding the 2-hr. timeframe for reporting an allegation of abuse and notifying local law enforcement of any allegation of abuse. Education was initiated by the inservice coordinator with all staff related to abuse prevention, investigation and reporting on 12/22/2023 and approximately 95% compliance was met as of 12/30/2023. An outside consultant was hired to provide assistance and was onsite on 01/02/2024 and 01/03/2024. The Abuse Prevention, Investigation and Reporting Policy was reviewed and revised again on 01/03/2024 with the assistance of the outside consultant to include compliance with all state and federal regulations. The lesson plan for abuse prevention/reporting and investigations was revised on 01/02/2024 and the consultant provided additional staff education starting 01/02/2024. As of 01/03/2024 approximately 50% compliance was reached. An educational session was recorded for ongoing use by the facility. Education will continue until compliance is met for all staff. A post-test was developed to validate staff knowledge of the content of the material. A lesson plan was developed by the outside consultant for abuse investigation and reporting with content directed to administrative staff who have responsibility for investigation and reporting of resident incident/accidents. An education session was conducted by the outside consultant with Administrative and Nursing Supervisory staff on 01/02/2024. On 01/02/2024, the outside consultant met with the Administrator to review their responsibilities for oversight of the facility?ÇÖs Abuse Prevention, Reporting and Investigation protocols, including reporting to the NYSDOH and local law enforcement per mandated timeframes. 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 practices. All occurrences or accident/incident reports related to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property from 09/01/2023 to present were reviewed by the Administrator and/or Acting Director of Nursing to determine if the 2-hr. reporting requirement was met. No additional occurrences related to reporting of allegations of abuse were identified and were not reported within the 2-hr. timeframe. The facility?ÇÖs QAPI Committee and outside consultant participated in a DP(NAME) QAPI meeting on 01/18/2024, to discuss the deficiency findings identified at F-609 and conducted a Root Cause Analysis. During this meeting, the outside consultant provided education to the Committee members on Abuse Prevention and compliance with the Federal reporting requirement and causative factors that resulted in the cited deficient practices. Education also addressed use of a Root Cause Analysis when compliance issues are identified. Based on the Root Cause Analysis that was part of the DP(NAME) QAPI meeting on 01/18/2024, the following issues were identified that required corrective actions: ?Çó The facility?ÇÖs policy and procedure related to Abuse Prohibition and Prevention did not address the current reporting guidelines and timeframes according to as stated in the current State and Federal guidance. ?Çó Facility staff did not have sufficient knowledge of carrying out their obligations and responsibility to comply with the reporting requirement of alleged abuse occurring in the nursing home. ?Çó Facility Administrator and DON responsible for investigating all occurrences needed to enhance their knowledge and understanding regarding their responsibility for meeting established reporting requirements in accordance with Federal and State regulation and directives. ?Çó The facility did not have the system process to ensure reported allegations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source and suspicions of a crime were reported per regulations. Effective 01/22/2024 the outside consultant will provide additional education to all facility staff on Abuse Prevention policy. ?Çó The education will include Abuse Prevention elements, the federal guidance on which occurrences are reportable, timeframes for reporting and how they should be reported. ?Çó Emphasis will be given to what constitutes abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, who is required to report, to whom allegation of violation will be reported and the reporting timeframes to the proper authorities. ?Çó This education will continue to be provided until all facility and agency staff receive this mandatory education. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). III. The following system changes will be implemented to assure continuing compliance with regulations: On 01/22/2024, the outside consultant along with the Administrator and Acting Director of Nursing will conduct an additional review and make any necessary revision of the policies and procedures related to Abuse Prevention Investigation and Reporting to ensure all requirements are included to ensure consistency with current Federal and State guidelines as stated in the State Operations Manual dated 10/24/2022. Abuse Prevention and Reporting education will be provided to all staff during orientation, on an annual and as needed basis with follow-up monitoring to ensure staff understands these protocols. The outside consultant will provide education and training to the Administrator, DON, ADON, and RN Supervisors on their responsibilities in conducting a thorough investigation and the timeliness of reporting of any alleged violations to the Administrator and other appropriate outside agencies/authorities meeting the 2-hr. reporting requirements when indicated, including the reporting of the results of the investigation, preventative and corrective actions taken within 5 business days. Effective 01/22/2024, the Director of Nursing/designee will monitor daily information shared at Morning Meeting and documented in the 24 Hr. Report and Incident/Accident Log to ensure that no allegation of abuse/crime has occurred. Immediate corrective action, such as completing an Incident/Accident Report and investigation, providing staff reeducation, or reporting to the state agency within the required timeframe, will be implemented as needed. The Director of Nursing/designee will continue to review all incident/accident reports to determine if there are occurrences that meet reporting requirements. The Acting Director of Nursing/designee will report all reportable events to the Administrator, the State Survey Agency, Local Law Enforcement or APS, to meet the 2-hr. abuse allegation reporting requirement. Effective 01/22/2024, a check of facility postings of Elder Justice Act signage regarding Protecting Adults from Abuse and Neglect, and Patient Care NYSDOH Hotline information will be completed to ensure facility staff, residents and visitors?ÇÖ have access to this information to report alleged violations. IV. The facility?ÇÖs compliance will be monitored utilizing the following quality assurance system: The facility will develop audit tools to monitor compliance with reporting of alleged violations involving abuse, neglect, exploitation, and mistreatment, including injuries of unknown origin and misappropriation of resident property to the Administrator and to the State Survey Agency, Local Law Enforcement, or other agency as per State Law and regulation. The Director of Nursing/designee will audit all occurrences of alleged violations the meet NYSDOH reporting requirement monthly for the next 3 months to ensure reporting requirements are met and reported timely to the NYSDOH and/or Local law Enforcement according to regulation and State law. Corrective actions, such as reeducation or submission of a report to the State Survey Agency or Local Law Enforcement, will be implemented when indicated. The DNS will provide a summary report of the NYSDOH reported occurrence audit findings to the QAPI Committee monthly for the next three months and then quarterly for evaluation and follow-up corrective actions. Responsibility: _Administrator_ |