Manhattanville Health Care Center
August 2, 2018 Complaint Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2018
Corrected date: September 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 580), the facility did not ensure that adequate supervision was provided to a resident to prevent an accident. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, Licensed Practical Nurse #1 (LPN #1), who was in the day room administering medications to the residents, gave permission to Certified Nursing Assistant #4 (CNA #4) to leave the day room. Resident #1 wandered out of the day room into Resident #2's room and Resident #2 used an over-bed table to push Resident #1 out of his room. Resident #1 fell and sustained an abrasion to the left knee. Findings: The facility's Policy and Procedure on Day Room Coverage was revised on 10/2016. The policy documented that the Certified Nursing Assistant assigned to provide day room coverage will remain in the day room with residents. The residents are not to be left unsupervised. The presence of the Activity Leader or Licensed Nurse in day room does not mean he/she is covering the room. The assigned CNA should remain in the day room. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 11/13/2017 documented that Resident #1 had short and long-term memory impairments. Resident #1's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). Resident #1 required limited assistance of one staff with walking and required extensive assistance of one staff with toilet use. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 11/03/2017 documented that Resident #2 had Brief Interview for Mental Status (BIMS-used to determine attention, orientation and ability to recall information) score of 13/15, (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Care Plan (CP) dated 06/14/2016 documented that Resident #1 exhibited the behavior of going into other residents' rooms and closets. He attempted to wear other residents' clothes, and had numerous episodes of laying in other residents' bed. A CP dated 02/23/2017 documented that Resident #1 puts on other residents' clothes. The interventions documented that staff should frequently check Resident #1's whereabouts, monitor and document changes in the resident behavior and redirect him as needed. The facility's Accident/Incident Report dated 12/21/2017 documented that at 6:45 PM Resident#1 came out of the bathroom in the hallway and went into Resident #2's room, where he searched through Resident #2's personal belongings. A staff responded to noise that was coming from Resident #2's room and observed Resident #2 pushing Resident #1 out of his room with an over-bed table. Resident #1 fell and sustained a 3cm x 0.5cm abrasion to his left knee. [MEDICATION NAME] Ointment applied to the left knee. A Dayroom Coverage Schedule dated 12/21/2017 documented that CNA #4 was assigned to cover the day room from 6:30 PM to 7:00 PM. A nurse's progress note, for Resident #1, dated 12/21/2017 documented that CNA #4 responded to noise that was coming from Resident #2's room at 6:45 PM. The CNA witnessed Resident #2 pushing Resident #1 out of the room with an over bed table. Resident #1 fell and sustained an abrasion. Resident #1 was last seen at 6:35 PM coming from the bathroom in the hallway. The Registered Nurse Supervisor (RNS) assessment revealed that Resident #1 had a 3cm x 0.5cm abrasion to his left knee. CNA#4 was interviewed on 07/30/2018 at 10:10 AM and stated that he was assigned to cover the residents in the day room from 6:30 PM to 7:00 PM. LPN #1 gave him permission to leave the day room and while he was in another resident's room, he heard noise coming from Resident #2's room and he responded. He saw Resident #2 using an over-bed to push Resident #1 out of his room and Resident #1 fell to the floor. Licensed Practical Nurse #1 (LPN #1) was interviewed on 08/02/2018 at 4:00 PM and stated that he was administering medications in the day room and was not aware that Resident #1 had left the day room. He stated that he gave CNA #4 permission to leave the day room and that he was not aware of the day room coverage policy, which stated that the CNA is to remain with the residents in the dayroom even with the presence of the Licensed Nurse. The Director of Nursing was interviewed on 07/26/2018 at 4:00 PM and stated that the medication nurse should not be monitoring the day room while administering medications. The CNA assigned to monitor the residents in the day room, must remain in the day room despite the nurse's presence. The facility does not have the capability to provide one on one supervision. 415.12(h)(1)

Plan of Correction: ApprovedAugust 15, 2018

(F689 I) Immediate Corrective Actions
1. Resident #1 was immediately assessed and NP notified
2. Resident #2 was also assessed and NP notified
3. Resident #1 was moved away from Resident #2. Resident #1 was taken to the day room
4. Posey Stop Sign Door Banner was attached to the door frame to prevent Resident #1 and other residents going inside the room of Resident #2
5. Care plan was updated for Resident #1 initiating hourly safety monitoring for as long as wandering behavior is manifested. This is reflected in the CNA Accountability Record
6. Re-inserviced staff and reviewed P&P Day Room Coverage
7. The DNS issued an educational counseling to LPN #1
8. The DNS issued an educational counseling to CNA #4 involved
(F689 II) Identification of Other Residents
1. The facility respectfully states that all residents can be potentially affected
(F689 III) Systemic Changes
1. On 8/10/18, the DNS/ADNS reviewed the Policy and Procedure on Day Room Coverage and found same to be compliant
2. On 8/10/18, the DNS/ Designee implemented staff in-service education for Policy and Procedure Day Room Coverage
3. On 8/13/18, Day Room coverage schedule form was updated/revised
4. On 8/13/18, all Department Heads were given a copy of the facility policy
5. Highlights of the Lesson Plan include:
? The rotation schedule for the CNAs posted in the Day Room which begins at 10:30 am and rotation of every 30 minutes
? The activities that must be carried out by the assigned CNA
A. If a resident wants to go to the bathroom, the Day Room CNA covering will call the Nursing Station and request help to toilet the resident
B. The Day Room CNA stays in the Day Room and continue supervision of the residents. Residents are not left unsupervised
? The presence of Activity Leader or Licensed Nurse does not mean he/she is covering the Day Room. The assigned CNA will remain in the Day Room in spite their presence
? The importance of notifying the nurse if an accident or incident or anything out of ordinary that happens in the Day Room
? The importance of the charge nurse making rounds in Day Room to ensure residents safety and activities going on
(F689 IV) Quality Assurance
1. DNS/ADNS developed an audit tool to monitor compliance with the Day Room coverage
a. Charge nurse initiates day room schedule
b. CNAs signs off the Day Room schedule form that they have completed their Day Room coverage.
c. Charge nurse signs off form at the end of the shift.
2. Audit will be done on each unit weekly x 4 weeks then monthly x 6 months
3. Findings of the audit will be brought to the Quarterly QA Meetings to check compliance and identify any areas of follow-up
(F689 V) Responsible Parties
? The DNS/Designee is responsible to ensure compliance with facility P&P Day Room Coverage