Willow Point Rehabilitation and Nursing Center
November 16, 2016 Complaint Survey

Standard Health Citations

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and interview conducted during the abbreviated survey (NY 776), it was determined for of 1 of 3 residents (Resident #1) reviewed for accidents, the facility did not consistently provide an environment free of hazards, or supervision and assistance to prevent accidents. Specifically, Resident #1 was at risk for falls and was not provided with a low bed during incontinence care, and fell out of bed sustaining injury when left unattended in an elevated bed position. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan dated 5/11/2016 documented the resident had periods of confusion and was non-ambulatory. He was at moderate risk for falls related to deconditioning, incontinence, and gait and balance problems. A documented goal was the resident was to be free from falls. Interventions included staff were to anticipate the resident's needs, provide a safe environment, keep the bed in low position at night, and personal items were to be kept within reach. The resident care care (care guide) dated 8/1/2016 documented staff were to ensure a fall mat was in place next to the bed for safety while the resident was in bed. The facility investigation report dated 8/1/2016 documented the resident was receiving incontinence care with his bed in the high position, when the certified nurse aide (CNA) assigned left his side to dispose of his soiled linen. The resident rolled out of bed to the floor. When assessed, the resident complained of back pain. The report documented resident was transferred to the hospital for evaluation and sustained a subdural hematoma and a fractured C6. The facility investigation did not document if the resident's fall mat was in place at the time of the incident. Hospital records dated 8/1/2016 documented the resident was admitted with a change in mental status with the development of a left dense hemiparesis (left-sided weakness) after a fall. He was found to have sustained a large acute subdural hematoma and possible C6 vertebra fracture. He required a craniotomy (surgical opening in skull) for evacuation (removal) of the subdural hematoma on the day of hospital admission. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment. He had impairment of one side of his upper and lower extremities, and required extensive assistance with all activities of daily living (ADLs). When interviewed on 9/26/2016 at 11:05 AM, CNA #1 stated she was assisting the resident in his room with incontinence care, the bed was in a high position and an air mattress was on top of the mattress. She stated the resident was high from the floor, above her waist, and, I am almost 6 feet tall. She stated she went to dispose of the resident's linen and the resident fell from the bed and he definitely hit his head on the floor. She stated she did not review the resident's plan of care prior to the incident, or know he was a safety risk. She stated she did not lower the bed as she did not think she would be gone that long. CNA #1 stated she continued to work in the facility for the remainder of the shift and the following shift without receiving re-education. When interviewed on 9/26/2016 at 12:55 PM, licensed practical nurse (LPN) #3 unit supervisor stated she was on the unit when the resident fell . She stated the resident was at moderate risk for falls due to his incontinence and instability, periods of confusion, and poor safety awareness. She stated she did not know if CNA #1 reviewed the resident's care guide for safety before providing care, and did not identify if the care planned interventions were in place prior to the incident. 10NYCRR 415.12(h)(1)(2)

Plan of Correction: ApprovedJanuary 16, 2017

Element #1
The facility assures that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. CNA #1 involved with resident #1 personnel file was reviewed and revealed there is no history or pattern of care issues, safety or care plan violations. CNA #1 involved with resident #1 was counseled on 8/02/2016 for failure to provide a safe environment for a resident. CNA#1 involved with resident #1 was re-educated on accident/incident prevention, lifting, and moving residents, bed making occupied bed on 8/2/2016. CNA #1 involved with resident #1 was re-educated on resident kardex (care guide) and accident/incident prevention on 01/12/2017.
Element #2
All residents at risk for falls were reviewed to ensure staff did not leave residents unattended while their beds were in an elevated position by 1/15/2017.
Element #3
1 CNA per shift per unit will be supervised by a licensed nurse to ensure safe practices are being followed when providing incontinent care to a resident for 1 week 1/16/2017-1/20/2017. All CNA's will be educated on the importance of not leaving the residents unattended while the bed is in the elevated position by 1/20/2017.
Element #4
Nursing administration will conduct audits on all residents who suffer a fall from bed to determine if the fall could have been prevented and if the plan of care was followed bimonthly for one (1) month; then monthly for two (2) months. The QAPI Committee will review the audits each month to determine if more audits/interventions are warranted. The facility threshold will be 100%. The Associate Director of Nursing and the Director of Nursing will be responsible for this plan of correction.

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report 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 to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2016
Corrected date: January 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the abbreviated surveys (NY 517 and NY 776), it was determined the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 2 of 3 sampled residents (Residents #1 and 2). Specifically, there was no documented evidence investigations were thorough and complete to rule out abuse, neglect, or mistreatment when Resident #1 rolled out of bed and sustained a subdural hematoma and a cervical fracture, and Resident #2 sustained a contusion (bruise) to her face and the facility investigation did not determine why the mechanical lift bar struck the resident during transfer. Additionally, the facility did not take actions to prevent further potential abuse while the two investigations were in progress, by removing involved staff from care provision and providing re-education timely. Findings include: 1) Resident #2 had [DIAGNOSES REDACTED]. The facility policy and procedure for mechanical lift transfers dated 5/2013 documented all staff involved in the transfer of the residents are responsible for and must ensure the safety of the resident. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required total assistance with all activities of daily living (ADLs). The undated CNA (certified nurse aide) resident care card (care instructions), presented as current, documented the resident was non-ambulatory, was at risk for falls, and was to be handled with care during transfers with a Vanderlift (mechanical lift). The facility investigation dated 7/5/2016 at 8:00 PM documented the resident had a bruised area above her left eye and was unable to state how the injury occurred. The investigative summary documented CNAs #1 and 2 transferred the resident into her bed from the shower, using a mechanical lift, and when CNA #2 unhooked the strap for the mechanical lift, the bar released and hit the resident in the left eye. The summary documented CNAs #1 and 2 failed to report the incident at the time of occurrence. The summary documented CNA #1 was no longer employed at the facility (she worked at the facility until 7/13/2016), and CNA #2 was re-educated on the proper technique of transferring a resident safely. The summary documented the family was not notified of the incident until 7/7/2016. The summary did not document who was responsible to notify the family, or if re-education was provided related to not notifying the family at the time of the incident. The summary documented the facility did not find evidence of abuse, neglect, or mistreatment, as the plan of care was followed. The statement provided by registered nurse (RN) #3 dated 7/13/2016 documented CNA #2 reported the incident to another staff member, and the facility was unable to identify any report from CNA #2. The facility did not provide documented evidence the nursing staff were interviewed on the incident. On 9/15/2016, a statement from RN #3 documented CNA #1 was assigned primary responsibility for the resident's care and CNA #2 was not. The facility investigation was not concluded at the time, as statements continued to be provided. The facility did not provide documented evidence CNA #2 received re-education as documented in the investigative summary on providing safety to residents during transfers, and did not document how to prevent reoccurence. When interviewed on 9/27/2016 at 8:00 AM, CNA #2 stated she was responsible for the resident's care on 7/5/2016, which was inconsistent from the investigation and statements provided. CNA #2 stated CNA #1 assisted her with the resident's transfer on 7/5/2016. She stated when she unhooked the resident from the mechanical lift strap, CNA #1 unhooked the strap from her end, and the bar flung back and hit the resident in the eye. She stated both she and CNA #1 reported the incident at the time it occurred and were unable to recall the name of the person to whom they reported the information. She stated she believed it was the day shift nursing staff. The facility investigation did not provide statements from the day shift nursing staff. When interviewed on 9/27/2016 at 9:00 AM, RN #3 stated upon her arrival to work on 7/6/2016, she was made aware of the incident that occurred on 7/5/2016. She stated the investigation began on 7/5/2016 at 8:00 PM when CNA #5 identified the bruised area on the resident's left eye. She stated the area was assessed by RN #6, who obtained a statement from CNA #1. She stated she had reported the information to nursing administration at that time, as she had concerns about CNA#1's previous care issues. She stated CNAs #1 and 2 remained working on the unit throughout the investigation. She stated she completed a summary of the incident approximately 2 weeks after the incident occurred. She stated she was unable to recall if she had obtained written statements from the nursing staff involved in the investigation and did recall she had talked to them. She stated she was unable to determine if CNA #2 reported the incident. She stated CNA #2 was not counseled or re-educated on the results of the incident. She stated she felt neglect had occurred and discussed the issue with nursing administration and followed their direction. When interviewed on 9/27/2016 at 9:30 AM, the Director of Nursing (DON) stated she reviewed the facility investigation, and her findings were that CNA #1 admitted she did not report the incident. She stated CNA #5 reported the incident and statements were obtained from staff who worked the previous 24 hours and they determined what had happened. She stated CNA #1 stated to RN #3 she did not report the incident at the time it occurred She stated statements were not obtained from some of the nursing staff and she believed CNA #2 was re-educated. The facility did not provide documented evidence re-education occurred for CNA #2, and CNA #1 remained working in the facility without re-education until 7/13/2016. The facility did not provide documentation the staff involved were monitored for safety issues during the investigation. When interviewed via telephone on 10/4/2016 at 2:15 PM, CNA #1 stated she was not the resident's primary aide and had assisted CNA #2 with the transfer on 7/5/2016. She stated she was located at the foot of the bed at the resident's feet when the strap was unhooked from the mechanical lift. She stated she was not aware the bar hit the resident's face until CNA #2 stated, Oh, it just hit her in the face. She stated after she completed the transfer, she assisted another CNA with care. She stated she believed CNA #2 alerted the nurse of the incident. She stated she did not report the incident as it slipped her mind. She stated she continued to work at the facility until she was terminated on 9/13/2016. 2) Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan dated 5/11/2016 documented the resident had periods of confusion, was non-ambulatory, and was at moderate risk for falls. A documented goal was for the resident to be free from falls. Interventions included staff were to anticipate the resident's needs, provide a safe environment, keep the bed in low position at night, and personal items were to be kept within reach. The facility policy for bed making, dated (MONTH) 2005, documented when a resident received incontinence care while in an occupied bed, the bed was to be placed in the lowest position for safety, and the call bell was to be within reach. Hospital records dated 8/1/2016 documented the resident was admitted with a change in mental status with the development of a left dense [MEDICAL CONDITION] (left-sided weakness) after a fall. He was found to have sustained a large acute subdural hematoma and possible C6 vertebra fracture. He required a craniotomy (surgical opening in skull) for evacuation (removal) of the subdural hematoma on the day of hospital admission. The facility investigation documented the resident had a fall out of bed on 8/1/2016 at 11:35 AM while being assisted with care, when the bed was in high position and had an air mattress on it. The resident complained of pain and was sent to the emergency room for evaluation. A registered nurse (RN) assessment was completed at the time of the incident. Certified nurse aide (CNA) #1 documented when she provided morning care, the resident had an incontinence episode, and she changed the resident. CNA #1 gathered his clothing, left the bed elevated, and went to dispose of his soiled linen in the bathroom. The Investigative Summary completed by licensed practical nurse (LPN) #3 documented the resident had poor safety awareness and a history of falls. The summary documented LPN #3 found no evidence of abuse, neglect, or mistreatment, as the plan of care was followed. The investigation revealed CNA #1 was counseled and re-inserviced on safety for the resident. The facility investigation did not document the height from which the resident fell , and did not provide statements from all staff involved. CNA #1 was not monitored after the incident occurred, and she remained in the facility and continued to provide care to residents on another unit. CNA #1's counseling and re-education was documented as provided on 8/2/2016. The inservice referral form was completed on 8/2/2016 and did not have documented evidence CNA #1 received the re-education on accident/incident prevention. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment. He had impairment of one side of his upper and lower extremities, and required extensive assistance with all of daily living (ADLs). When interviewed on 9/26/2016 at 11:05 AM, CNA #1 reported she was Resident #1's primary aide. She stated she was not familiar with his care instructions, as she had only provided care for him for a few days and had not reviewed the resident care plan prior to providing care. She stated she was provided with a cheat sheet for the resident's care instructions and was not aware the resident had poor safety awareness. She stated she had provided incontinence care for the resident with the bed elevated at her waist height and reported she was almost 6 feet in height, and stated the bed was pretty high and had a air mattress on it. She stated she assumed the resident would be okay. She stated she placed his soiled linen on the floor, completed the resident care, disposed of the soiled linen, and turned to see the resident falling. She stated she called out for assistance. She stated a reenactment of the incident was completed and she was aware she did not provide safety for the resident. She stated she did not receive education for failure to follow the resident's plan of care and continued to work on another unit in the facility for 8 more hours. When interviewed on 9/26/2016, RN #2 stated she provided a statement to the facility for the incident. She stated she assessed the resident at the time of the incident and sent the resident out to the hospital for evaluation. There was no documented evidence the investigation included RN #2's statement. When interviewed on 9/26/2016 at 12:55 PM, LPN #3 stated the facility completed a reenactment of the incident at the time of occurrence. She stated the resident was at moderate risk for falls and had some safety awareness. After review of her documented summary reporting the resident had poor safety awareness, she stated, I guess he did have poor safety awareness. When asked how she determined there was no evidence of abuse, neglect, or mistreatment, she stated CNA #1 made a poor decision, but she did not do it intentionally. She stated she did not know if CNA #1 reviewed the resident's plan of care. LPN #3 defined neglect as when someone's needs were not met. When interviewed on 9/26/2016 at 1:15 PM, the Associate Director of Nursing (ADON) stated she was responsible for reviewing all investigations once they were completed on the units. She stated she completed a reenactment of the incident at the time the incident occurred. When asked at what height the bed was positioned, she stated waist height while using herself as the height measurement. She stated she believed the investigation was complete. Upon review of the investigation with the surveyor, she stated the plan of care was followed as the resident required assist of one person for care, CNA #1 had on the appropriate isolation attire, and the resident's linens were disposed of properly. The ADON stated the staff were to review residents' care instructions if the the staff had not provided care for the resident in a while. She stated she was aware the resident had poor safety awareness and she did not feel CNA #1 was neglectful, as she had soiled linen to dispose of and she had to put it in the bathroom. She stated she was unable to determine why CNA #1 was re-educated and counseled for safety if there was no evidence of abuse, neglect, or mistreatment. When interviewed on 9/26/2016 at 1:30 PM, the Director of Nursing (DON) stated she had completed the investigation of Resident #1's fall. The DON stated she advised staff to complete a reenactment, and alerted CNA #1 she would be sent for re-education on safety. She stated she did not provide monitoring for CNA #1, as she did not believe neglect had occurred. She stated the Supervisor was aware of the incident and kept a eye on her. There was no documented evidence CNA #1 was supervised until she was re-educated on safety. When interviewed on 11/16/2016 at 9:07 AM, the Administrator reported when abuse, neglect, or mistreatment were suspected, he placed staff on suspension pending the outcome of the investigation and the staff were re-educated prior to returning to work at the facility. He reported he did not re-educate the staff involved at the time of the incident and for one CNA involved, re-education did not occur until 9/30/2016. He reported the staff were interviewed at the time of the incident and written statements were not obtained, as that was at the discretion of the Unit Manager. He reported the staff continued to work in the facility during the investigation, as there was nothing to indicate abuse, neglect, or mistreatment occured. 10NYCRR 415.4(a)(2-7)

Plan of Correction: ApprovedJanuary 16, 2017

F225
Element #1
The facility assures that all alleged violations involving mistreatment, neglect, or abuse are thoroughly investigated. CNA #2 was re-educated on 9/29/2016 on accident/incident prevention and procedures to follow when using a mechanical lift. The nurse responsible for not notifying the family of resident #2 of the incident on 7/5/2016 in a timely manner was re-educated on the Accident/incident report and QA-resident policy on 8/12/2016. RN #3 was counseled on 9/28/2016 for failure to follow through with ensuring the re-education for CNA #2 regarding accident/incident prevention and procedures to follow when using a mechanical lift was completed as stated in the investigative summary for the incident on 7/5/2016 involving resident #2. CNA #1 who was involved with resident #2 was terminated from employment on 7/13/2016.
Element #2
All investigations involving a resident with a bruise of unknown origin from 12/1/2016-01/12/2017 will be reviewed for completeness and thoroughness of the investigations by 01/15/2017.
Element #3
The abuse prevention, abuse reporting and investigation and accident/incident report-QA-resident policies were reviewed and updated. All nursing supervisors were inserviced on the updated policies and procedures to complete a thorough investigation involving any alleged violations of mistreatment, neglect or abuse on 10/12/2016. The abuse prevention, abuse reporting and investigation and accident/incident report-QA-resident were reviewed and updated again on 01/13/2017. All staff will be inserviced on the updated policies by 01/20/2017.
Element #4
Nursing Administration will conduct audits of investigations involving bruises of unknown origin up to 10 residents bi-monthly for one (1) month; then monthly for two (2) months for completeness and thoroughness.
The QAPI Committee will review the audits each month to determine if more audits/interventions are warranted. The facility threshold will be 100%.
The Associate Director of Nursing and the Director of Nursing are responsible for this plan of correction.

Element #1
The facility assures that all alleged violations involving mistreatment, neglect or abuse are thoroughly investigated. CNA#1 involved with resident #1 was counseled on 8/02/2016 for failure to provide a safe environment for a resident. CNA#1 involved with resident #1 was re-educated on accident/incident prevention, lifting, and moving residents, bed making occupied bed on 8/2/2016. CNA#1 involved with resident #1 was re-educated on reading resident kardex (care guide) and accident/incident prevention on 1/12/2017.
Element#2
All investigations involving a resident falling from bed onto the floor from 12/1/2016-01/12/2017 will be reviewed for completeness and thoroughness of the investigations by 1/15/2017.
Element #3
The abuse prevention, abuse reporting and investigation and accident/incident report-QA-resident policies were reviewed and updated. All nursing supervisors were inserviced on the updated policies and procedures to complete a thorough investigation involving any alleged violations of mistreatment, neglect or abuse on 10/12/2016. The abuse prevention, abuse reporting and investigation and accident/incident report-QA-resident were reviewed and updated again on 01/13/2017. All staff will be inserviced on the updated policies by 01/20/2017.
Element #4
Nursing Administration will conduct audits of investigations involving falls from the bed for up to 10 residents bi-monthly for one (1) month; then monthly for two (2) months for completeness and thoroughness. The QAPI Committee will review the audits each month to determine if more audits/interventions are warranted. The facility threshold will be 100%. The Associate Director of Nursing and the Director of Nursing will be responsible for this plan of correction.