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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard survey started on 9/27/22 and completed on 10/3/22, the facility did not have documentation for the weekly supervision of employees that were subject to the New York State Department of Health Criminal History Record Check (CHRC) and had not yet received a determination letter from the CHRC Legal Review Unit. Specifically, two (Employee #1 and Employee #3) of four employees reviewed for CHRC negative determination findings did not have documentation of weekly supervision. The findings are: The facility's policy and procedure titled, Criminal History Record Checks (CHRC) NYS DOH, modified 3/19/21, documented all temporary/ provisional staff members must be properly supervised and documentation of such supervision must be maintained. The Temporary/ Provisional Staff Supervision Log must be completed by the subject individual's Department Head/ Supervisor for each day they are working under provisional status. Once the CHRC is cleared or the CHRC notifies the facility that the subject individual must be removed from work, the log must be returned to the Human Resources Coordinator and placed in the personnel file. 1a. Review of the Human Resources file for Employee #3 (Maintenance Assistant) revealed their hire date was 5/4/22 and their CHRC negative determination letter was dated 5/10/ 22. The file did not contain documentation for provisional supervision during that time. Review of the automated time and attendance record revealed Employee #3 attended General Orientation on 5/4/22 and worked on resident units for five shifts between 5/5/22 and 5/10/ 22. 1b. Review of the Human Resources file for Employee #1 (Agency Certified Nurse Aide) revealed their first date worked in the facility was 1/1/22 and their CHRC negative determination letter was dated 1/7/ 22. The file did not contain documentation for provisional supervision during that time. Review of the automated time and attendance record revealed Employee #1 worked four shifts at the facility between 1/1/22 and 1/ 722. During an interview on 9/29/22 at 11:40 AM, the Human Resources Manager (CHRC Authorized Person) stated during the first few weeks of employment, new employees and agency staff members are monitored, but a supervision log should always be filled out until the CHRC result is received. Additionally, on 10/3/22 at 10:05 AM, the Human Resources Manager stated they did not have any documentation of provisional supervision for Employee #3 or Employee #1 and they would have expected a supervision log to be filled out for both. They further stated Employee #3 and Employee #1 could have worked on all four resident units during their provisional time. 402. 4 402. 6(d) | Plan of Correction: ApprovedApril 29, 2025 Element#1 What corrective actions(S) will be accomplished for those residents found to have been affected by the deficient practice Residents #1 who was affected by this deficient practice was assessed by RN Supervisor (RNS), PMD and Psychiatrist. Right periorbital xray was ordered and result showed no fracture. Accused RN was immediately removed from duty. Completed 4/17/2025 Element #2 How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents under the care of accused RN had the potential to be affected by the deficient practice, consequently, upon report of occurrence on 9/7/2023, the accused RN was immediately removed from duty and employment subsequently terminated. Cognitively intact residents who were under the care of accused RN will be interviewed and assessed for abuse or inappropriate interactions. Resident who are cognitively impaired, their NOK will be interviewed instead. Completed 6/3/2025 Element#3 What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Facility Abuse prevention policy and procedure was reviewed and revised to include, staff accused of abuse must be removed from duty immediately All employees, will be monitored by their respective department head to ensure they are not abusing residents. Specifically, unit CNA, LPN and RN will be monitored by RN Supervisor. ADNS will supervise RNS for any inappropriate or abusive interactions with residents. Employees identified with behaviors or negative interactions that equates to abuse will be removed from duty immediately. All resident will be monitored by unit RN Supervisor and Social Worker to ensure they are not abused by staff. All staff who directly interact with resident- such as nursing, medical, housekeeping, social work, activities, rehabilitation and administration- will be re-inservice on abuse prevention by ADNS and/or their direct supervisor. Social Work Director and/or designee will attend monthly resident council meeting to educate resident on procedure for promptly reporting abuse DNS will monitor for sustained compliance of staff abuse prevention education and observation to ensure all residents are free from staff abuse. Completed by 5/31/25 Element#4 How the corrective actions(s) will be monitored to ensure the deficient practice will not recur ?ö?ç?ú what quality assurance program will be put into practice Social Worker will audit/interview 5 residents weekly to assess comfort with caregivers and/or report of abuse and report to DNS and/or Administrator of their findings . Negative findings will be addressed promptly. ADNS will conduct weekly audit of direct staff interaction with resident on unit and report to DNS and/or Administrator of their findings; Negative findings will be addressed promptly. Audit findings will be reported and reviewed at QAPI weekly x 2 weeks; monthly x 2 months, then quarterly thereafter. Completed by 5/31/2025 Element #5 The date for correction and the title of the person responsible for correction of each deficiency Director of Nursing and/or designee Date __6/3/2025______________ |