Eddy Village Green
April 24, 2017 Complaint Survey

Standard Health Citations

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor:(NAME)B. Based on record review and staff interview during abbreviated surveys (Complaint #s NY 903 and NY 259), the facility did not have evidence that all alleged violations were thoroughly investigated, and did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported to the State Survey Agency in accordance with State law through established procedures for 3 (Resident #s 2, 4 and 5) of 10 residents reviewed. Specifically, for Resident #5 the facility did not provide evidence of a thorough investigation after the resident alleged that a Licensed Practical Nurse (LPN) was threatening, and the resident was afraid of him. For Residents #2 the facility did not report a resident-to-resident incident, and for Resident #4 the facility did not report an alleged misappropriation of resident property in a timely manner. This is evidenced by the following: The Abuse Prevention and Investigation Protocol dated 11/28/16, documented that the facility was to follow all federal and state regulations, Dear Administrator Letters and the Centers for Medicare and Medicaid Services (CMS) State Operations Manual. Any staff member who may have had knowledge of an incident, including the perpetrator, was to be interviewed and asked to provide a written statement. The New York State Department of Health (NYSDOH) Nursing Home Incident Reporting Manual dated 8/2016, documented that resident-to-resident incidents that cause injury (including bruises, skin tears, etc.) are reportable to the NYSDOH. The Incident Reporting Manual also documented that cases of misappropriation of resident property was to be reported to the NYSDOH immediately, defined as not to exceed 24 hours after discovery of the incident. Resident #5: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], assessed the resident had modified independence in cognition. A Social Work Department Registration of Grievance dated 1/26/17, documented Resident #5 reported he was afraid of LPN#1, and he did not want to see him again. On 1/24/17, LPN#1 spoke to him in a threatening manner, his voiced was raised and he was very close to (the resident's) face. The resident requested that LPN#1 not give him medications, visit him or provide care for him. The Director of Nursing (DON) investigated the report on 1/27/17, and wrote in the Plan of Action section that an eye witness revealed LPN#1 was professional and appropriate during the alleged incident. The witness had reported the resident was yelling and threatening to hit the witness, when LPN#1 came into the room to see how he could help diffuse the situation. LPN#1 was no longer to provide medications to this resident. The Registration of Grievance was signed by the DON, the Administrator and the Director of Social Work. During an interview on 4/19/16 at 2:38 pm, the Assistant Director of Nursing (ADON) stated there were no Written Statements to go with the 1/26/17 Registration of Grievance, and that she believed the Administrator had an unsigned statement from Certified Nursing Assistant #1 (CNA, also known as a Shahbaz in this facility). CNA#1 was the eye-witness referred to in the Report of Grievance. During an interview on 4/2/17 at 11:02 am, the DON stated she interviewed both LPN#1 and CNA#1, but did not document those interviews Resident #2: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], assessed the resident had severely impaired cognition. An Investigation Summary Form documented review of the facility surveillance cameras on 3/16/17 at 6:08 pm showed this resident was at the dining room table when a CNA noted that another resident had bitten this resident's arm. An assessment by a Registered Nurse (RN) found this resident's right forearm was bruised, although the skin was intact. The facility investigation concluded that no abuse had occurred. A Nursing Progress Note dated 6:44 pm, documented the RN assessed this resident after being bitten by another resident. This resident had a 3 centimeter (cm) long by 2.6 cm wide bruise on the right forearm. The skin was intact but slightly swollen. A CNA Progress Note dated 3/16/17 at 10:00 pm, documented the resident had a bite on here right forearm that came from another resident. During an interview on 4/19/16 at 2:38 pm, the Assistant Director of Nursing (ADON) stated that after reviewing the video of the incident, and because there was no harm beyond a bruise, the facility did not believe this incident was reportable to the NYSDOH. Resident #4: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severe cognitive impairment. A Progress note dated 2/8/2017, written by the Registered Nurse Case Manager (RNCM) at 8:25 pm, documented the program manager from the resident's previous facility gave her $560.00 in one envelope and $32.00 in a second envelope that belonged to Resident #4. She documented it was locked in the narcotic cabinet pending deposit in the resident's personal account. An Investigation Summary Form documented that when the resident was admitted to the facility after normal business hours on 2/8/17, two envelopes containing cash (a total of $592.00) were given to the Registered Nurse Case Manager (RNCM). The RNCM placed the cash in the narcotic cabinet until the next day when the business office opened. On the morning of 2/9/17, staff discovered $192.00 was missing from the envelopes. The facility notified the Police Department on 2/10/17. The DOH Intake Information form documented the facility reported the theft to the DOH on 2/13/17 at 5:24 pm. During an interview on 4/20/17 at 4:02 pm, the Administrator stated she reported the alleged theft to the Police Department on 2/10/17. She stated the Elder Justice Act mandated that there was a 24 reporting timeframe for notifying law enforcement of any suspected crime. She stated she was not aware of a 24-hour mandate for reporting misappropriation of resident property to the NYSDOH. 10 NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedMay 5, 2017

The Grievance policy has been amended to indicate that any grievance that could be considered abuse, mistreatment or neglect must be handled under the Abuse Investigation protocol. Education to the Social Work Dept on the new policy will occur.
Responsible Party: Administrator
Administration, Nursing Administration, Nurse Managers Social Workers and Guides will review the new grievance policy, 483.12, as well as the Nursing Home Incident Reporting Manual, published by the New York State Department of Health, August, (YEAR). Inservice will review 1. what is reportable, 2. timeframes for reporting, 3. investigation protocol
Responsible Party: Administrator
All I&As will be reviewed weekly to insure that issues are appropriately being identified for investigation. Results will be reported to QAPI Committee monthly until two consecutive months of 100% compliance are achieved. Subsequently, a monthly audit of 20 random I&As will be reviewed and reported to QAPI quarterly through (YEAR). Additionally, all investigations will be reviewed for 1. appropriate identification of reportable incidents to DOH and 2.timely reporting of incidents. Results will be reported to QAPI monthly until six months of 100% compliance is achieved.
Responsible Party: Administrator
All grievances will be reviewed to insure they are being referred to the Abuse Investigation policy when appropriate. 100% of grievances will be reviewed and reported to QAPI committee monthly until three consecutive months of 100% compliance are achieved.
Responsible Party: Director of Social Work

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2017
Corrected date: June 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care for 1 (Resident #1) of 10 residents reviewed during a complaint investigation (Case #NY 259). Specifically, Resident #1 was administered PRN (as needed) [MEDICATION NAME] without indication that the resident required the medication at that time. This is evidenced by: Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severe cognitive impairment. The undated Pain Management Standard of Care (S(NAME)) documented staff were to note non-verbal pain cues such as vital sign changes, guarding and emotional behavior. Medications were to be administered as ordered, and staff were to use a pain rating scale. The Hospice Team Care Plan for Pain dated 4/13/17, documented staff were to assess pain weekly and PRN, and the resident was to receive [MEDICATION NAME] as ordered. An untitled document dated 2/3/17, and provided by the facility, described the pain scales nurses were to use for cognitively intact, and cognitively impaired residents. For cognitively intact residents, nurses were to evaluate pain on a 0 to 10 scale, where 0 meant no pain and 10 meant excruciating pain. For cogitatively impaired residents, nurse were to evaluate pain based on outward signs related to breathing, negative vocalization, facial expressions, body language and consolability. Each section was assigned a numeric value, which was added up for a total pain score. The Medication Administration Record (MAR) for 4/2017, documented the resident was to receive comfort measures only, and 20 milligrams (mg) of [MEDICATION NAME] sulfate (an opiate pain medication) by mouth every hour PRN for distress. Licensed Practical Nurse (LPN) #1 documented on the MAR that the resident received the PRN [MEDICATION NAME] at 8:09 pm on 4/10/17, and that the effectiveness of the medication was unknown. There was no documentation of the resident's pain scale on the MAR. Review of Progress Notes for 4/10/17, revealed no documentation of the resident's pain scale. An undated Written Statement signed by LPN#1 documented that on 4/10/17, at approximately 7:30 pm, the resident was resistant to being given PRN [MEDICATION NAME] by mouth. He wrote the resident showed no signs or symptoms of pain, and she did not want or need the medication at that time, and he had administered it to appease the family. During an interview on 4/19/17 at 1:00 pm, LPN#1 stated when he went into the resident's room at approximately 7:30 pm on 4/10/17, the resdient appeared to be asleep, was docile and there was no evidence of pain. When he administered the medication in the resident's mouth, she became combative, was shaking her head and spitting the [MEDICATION NAME] out. He stated, he gave the medication because the family ran the show and wanted the PRN [MEDICATION NAME] to be given even if she did not show evidence of pain, and that was what he and other staff did to keep the resident's family happy. He stated it never occurred to him to call a nursing supervisor because the family ran the show so he did what they wanted. On the Medication Administration Record (MAR) for 4/2017, LPN #2 documented she had given the resident PRN [MEDICATION NAME] once on 4/5/17, twice on 4/7/17, three times on 4/10/17 and twice on 4/12/17. There was no documentation of the resident's pain scale on the MAR for these dates. Review of Progress Notes for 4/10/17, revealed no documentation of the resident's pain scale. In a Nurses Note dated 4/10/17 at 7:21 pm, LPN#2 documented the resident's family wanted the resdient to receive [MEDICATION NAME] every hour. During an interview on 4/19/17 at 2:15 pm, LPN#2 stated that most of the time when she gave this resident the PRN [MEDICATION NAME], the resident was showing no signs or symptoms of pain, and that she gave it to make the family happy. She stated the family was suffering, and was very concerned about the resident's comfort, so giving the medication when the family wanted it made sense, even if the resident did not appear to need the PRN [MEDICATION NAME] at that time. During an interview on 4/19/17 at 11:42 am, the Director of Nursing (DON) stated this resident's family was very involved with the resident. She stated there may have been times the resident was in pain, and the family called for a nurse, but when the nurse arrived the resident may not have looked like they were in pain. In a case such as this, she would expect the nurse to administer the medication based on the family having reported the resident having been in pain. She also stated that, absent such a circumstance, PRN medications should not be given as a scheduled dose without evidence that showed the need for the PRN medication. Additionally, if a nurse had questions about the appropriateness of giving a PRN medication, that nurse should contact a Registered Nurse Supervisor. 10 NYCRR 415.11(c)(3)(ii)

Plan of Correction: ApprovedMay 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LPN#1 and LPN#2 that will receive corrective action for failure to follow facility care standards related to the administration of prn pain medication.
Responsible Party: Director of Nursing
All licensed nursing staff will be re-trained on the pain scales used for cognitively intact and cognitively impaired residents and required documentation of pain/distress level indicating the use of PRN pain medications.
Responsible Party: Director of Nursing
A review of 100% of residents receiving prn [MEDICATION NAME] will be completed to identify appropriate documentation of s/s of pain/distress indicating use of the prn [MEDICATION NAME]. Results of the audit will be reported to QAPI in (MONTH) and (MONTH) (YEAR). Monthly reviews will continue until 95% compliance is achieved for two consecutive months. Staff with a pattern of noncompliance will be addressed with the facility's progressive corrective action policy, up to and including termination of employment and reporting to the State licensing board.
Responsible Party: Director of Nursing