Fort Hudson Nursing Center, Inc.
March 29, 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: March 29, 2017
Corrected date: June 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview during an abbreviated survey (Case #NY 137), the facility did not ensure that all alleged violations involving abuse, neglect, or mistreatment were reported to the Administrator of the facility and to the New York State Department of Health (NYS DOH) immediately (within 24 hours) after the discovery of the alleged incident, did not remove the facility staff member from resident care and simultaneously initiate an investigation to prevent further potential abuse for one resident (Resident #1) of four residents reviewed (Residents #s 1, 4, 5 and 6). Specifically, for Resident #1, facility staff did not report an incident that occurred on 12/17/16 and met the reasonable cause threshold that involved an alleged violation of abuse, neglect and mistreatment, to administration and the NYS DOH. Also, the facility did not simultaneously initiate an investigation to prevent further potential abuse until 12/19/16, did not remove a Registered Nurse Supervisor (RNS) from resident care while the investigation was in progress and did not report the 12/17/16 incident that met the reasonable cause threshold to the NYS DOH until 12/21/16. This is evidenced by: Federal (42 CFR 483.13) and State (10 NYCRR 415.4) regulations require the facility to report alleged violations of mistreatment, neglect and abuse immediately to the administrator of the facility and to other officials in accordance with the State law, not to exceed 24 hours after the discovery of the incident. The facility must simultaneously initiate an investigation and prevent further potential abuse while the investigation is in progress. 10 NYCRR, Section 81.1(d) defines reasonable cause to mean that upon review of the circumstances, there is sufficient evidence for a prudent person to believe that physical abuse, mistreatment, or neglect has occurred. Circumstances that may lead to a reasonable cause conclusion may include, but are not limited to: A statement that physical abuse, mistreatment or neglect has occurred, the presence of a physical condition (such as a bruise) that is inconsistent with the resident's history or course of treatment, or the visual or auditory observation of an act or condition of physical abuse, mistreatment or neglect. An Administrative Policy revised in 2/2015 for Abuse (Resident) Reported documented, The first priority if witnessed or suspected abuse, neglect or mistreatment of [REDACTED]. Remove the resident from the situation (which may be accomplished by removing the offending party). A Policy and Procedure titled Abuse Investigative Process revised on 2/2015, documented the Director of Nursing (DON) or the Administrator of Record (AOR) must report qualifying incidents to the NYS DOH within 24 hours via the online electronic incident reporting form. If the NYS DOH online system is down, the incident can also be reported via the NYS DOH centralized complaint intake phone line. A Policy and Procedure titled Abuse (Resident) Reporting revised on 2/2015, documented mistreatment will be reported to NYS DOH when the following element is present: Intent OR recklessly performing an act. Neglect will be reported to NYS when one of the following elements is present: Intent OR recklessly performing an act, failure to follow care plan with injury, and repeat failure to follow care plan with or without injury. A Policy and Procedure titled Abuse (Resident) reporting revised on 2/2015 documented under General Considerations the following: Every employee is required to report occurrences of actual or suspected abuse, neglect or mistreatment including misappropriation of resident's property. Failure to report is a violation of Public Health Law. The document titled Your Rights as a Nursing Home Resident in New York State and Nursing Home Responsibilities dated (MONTH) 2010, documented the nursing home's responsibility was to protect residents from any kind of harsh and abusive treatment. Resident #1: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her Minimum Data Set ((MDS) dated [DATE], indicated moderate cognitive impairment. There was no change in cognitive status compared to her 10/15/16 MDS. Observation of a security video on 2/16/17 revealed that on 12/17/16 at approximately 10:15 pm, Resident #1 was abruptly awakened from slumber, forcibly removed from the lobby sofa, forcibly put into a wheelchair (W/C) and taken back to the unit. Registered Nurse Supervisor #1 (RNS) and Certified Nursing Assistant #1 (CNA) lifted the resident off the couch and placed the resident in the W/C. RNS #1 held the resident in the W/C to prevent the resident from getting up, and wheeled the resident backward in the W/C out of the lobby. A record of RNS #1's time clock punches documented she worked on 12/17/16 from 7:00 am-11:00 pm, 12/18/16 from 7:00 am-11:00 pm, 12/24/16 from 7:00 am-11:00 pm and continued working every weekend following the incident until her resignation on 2/27/17. A Nurse's Note (NN) dated 12/17/2016, written by Licensed Practical Nurse #1 (LPN) stated she was aware the resident was sleeping in the lobby upon her arrival for the 10:00 pm-6:00 am shift. She was told by RNS #1 to get the resident back to her room. RNS #1, LPN #1 and CNA #'s 1 and #2 went to the lobby with a W/C to get the resident. RNS #1 woke the resident up. The resident was angry and combative. The resident refused to go to her room because her roommate was noisy; had the lights and TV on in the room; and she was not going anywhere. The resident attempted to sit on the floor and RNS #1 and CNA #1 guided resident to the floor and then assisted her back up. RNS #1, CNA #1 and LPN #1 were able to maneuver the resident back to her room in the W/C. CNA #1 held the resident's right hand and RNS #1 held the resident's left hand and arm. A NN dated 12/18/16 at 5:15 am, written by RNS #2, documented she assessed the resident's left wrist, hand and lower forearm. There were two medium bruises. It documented RNS #2 had received report that the resident did not want to return to her room and was escorted back to her room at approximately 10:15 pm (on 12/17/16). A NN dated 12/18/16 at 11:57 am, written by RNS #1, documented the resident was sleeping in the lobby. She woke her up and asked why. The resident told her because her roommate was too noisy. RNS #1 told staff to get a W/C and bring the resident back to the unit. She documented CNA #1 and she picked the resident up under her arms and sat her in the W/C. The resident started yelling, I don't want to go to my room. She stated, I'm going to sit on the floor and attempted to do so. RNS #1 documented the resident did not sit on the floor and was assisted back to the W/C. LPN #1 pulled the W/C and CNA #1 and RNS #1 walked by the resident's side to try to prevent the resident from injuring herself as she hit at staff. The resident was noted to have reddened areas on both arms, but no bruising. In the morning, bruising was present. There were several bruises on each arm. RNS #1 approached the resident and talked with her. When RNS #1 asked to check her arms the resident stated, They twisted my arms and bruised them. Get out. You are just like the rest of them. An email dated 12/19/16 at 5:31 am from RNS #2 to the Director of Nursing (DON) regarding the 12/17/16 incident, documented staff that were involved in the incident with the resident had come to her with their concerns that night and told her they were very uncomfortable with the situation and it just felt wrong. She stated the witnesses reported to her that RNS #1 was very rough with the resident, grabbed her, forced her into a W/C and held her down. The resident told RNS #1 she was hurting her. There was significant bruising to her left arm. A NN dated 12/19/16 at 2:56 pm, written by the Assistant Director of Nursing (ADON) documented she did a full body audit of the resident. The ADON documented the resident had two circular bruises on her right arm, close to the size of her watch, however, the diameter was a little larger than the face of the watch. She also documented the resident was noted to have bruising on her left hand and wrist area. There was no documented evidence that staff statements were obtained or an investigation started prior to 12/19/16 for the 12/17/16 incident that involved Resident #1. A document titled (facility named) Internal Case Review documented the internal review was initiated on 12/19/16, and completed on 12/20/16. It concluded physical abuse could not be fully ruled out, so the incident would be reported to the NYS Department of Health (DOH). A document titled Intake Information, (the report form completed by the Nursing Home abuse hotline staff) documented the incident was reported to the NYS DOH on 12/21/16 at 5:17 pm by the DON. Documents from the (facility named) Health System dated 12/21/16, were given to CNA #1, CNA #2, CNA #3 and RNS #2 to inform them that the alleged incident that occurred on 12/17/16 with Resident #1 had been reported to the NYS DOH on 12/21/16. A document dated 2/27/17, submitted to the Director of Nursing (DON) by RNS #1 documented the resignation of RNS #1. An email sent on 3/23/17, from the Administrator on Record (AOR), documented an undated summary of the telephone counseling she gave to CNA #1 (12/19/16), CNA #2 (12/19/16) and LPN #1. A voicemail message was left for LPN #1 on 12/19/16 but she did not return the call until 12/23/16. The summary documented the counseling provided included the following: First and foremost, they are mandated reporters. They are to report to the Administrator or DON if uncomfortable in a situation and/or the direction they are being given. They were to intervene immediately by going up the chain of command if necessary. During a phone interview on 2/16/17 at 1:37 pm, LPN #1 stated she worked the 10:00 pm -6:00 am shift on 12/17/16. She stated the resident was forced to go back to her room by RNS #1. She stated she could not report the incident to RNS #1 because she was involved in the incident. She stated she told RNS #2. During an interview on 2/16/17 at 4:30 pm, the AOR stated she first found out about the incident when she received a voicemail message on 12/19/16 upon her arrival to work. She stated it was left by CNA #3 on 12/18/16. She stated she went to see the resident who showed her arms and stated, Look what they did to me, there were four of them on me. During a phone interview on 2/22/17 at 3:18 pm, RNS #2 stated she worked the 11:00 pm-7:00 am shift that started on 12/17/16. She stated RNS #1 reported the incident that involved Resident #1 to her when she started her shift that night. RNS #2 stated she went to assess the resident's bruising. She stated the bruising was on the resident's left hand, wrist and forearm. She stated the bruising extended around the circumference of her arm and did not appear to her the resident's arm had not been held with an open arm. She stated the CNA's involved with the incident were very upset. During an interview on 2/27/17 at 8:55 am, RNS #1 stated she did not realize how out of control the situation had gotten. She stated she should have reported it to the DON at that point. She stated the staff involved and she were all mandated reporters of abuse, neglect and mistreatment. She stated she did not know if the staff involved reported the incident. She stated the Administrator told her it was a State reportable incident. She stated she did not do an incident report or document the incident in the NN until the bruising was brought to her attention on 12/18/16. During a phone interview on 3/2/17 at 10:43 am, CNA #2 stated the 12/17/16 incident made her feel uncomfortable; she did not like the way RNS #1 handled the situation. She stated she would report an allegation of abuse, neglect or mistreatment when it occurred, but couldn't voice her concerns to RNS #1 because she was the one involved. She stated she did tell RNS #2 about it but did not know what she did with the information. She stated she could have called the DOH reporting number, but had never used it and would have to ask for it. She stated she thought they had 48-72 hours to report an incident. During a phone interview on 3/2/17 at 11:46 am, CNA #1 stated she felt uncomfortable with the incident that occurred on 12/17/2016. She stated she felt like RNS #1 attacked and mistreated the resident. She stated it made her feel angry and she discussed it briefly with LPN #1. She stated she did not go any further with reporting the incident because she had told LPN #1. She stated she could not report to RNS #1 because she was involved in the incident and wasn't really sure who to report to at that point. She stated, what was I supposed to do; call the DON or AOR at midnight? She also stated she was never asked to write a statement until the 10:00 pm-6:00 am shift on 12/19/16; 24 hours after the incident occurred. During an interview on 3/8/17 at 2:02 pm, with the Physician's Assistant (PA) she stated she learned of the 12/17/16 incident on 12/21/16 when the Registered Nurse Manager (RNM) reported to her the resident had a Personal Watch on as a result of exit seeking behavior related to the 12/17/16 incident. She stated she was told the resident was forcefully and inappropriately removed from the lobby and had bruising. During the course of the interview, she viewed the security video of the incident. She stated she did not feel what staff did was appropriate on any level and she would have reported it to Administration. During an interview on 3/8/17 at 4:30 pm, the Director of Nursing (DON) stated, She (RNS #1) made a mistake. If we let every nurse go that made a mistake, we wouldn't have any working here. She acknowledged the incident was a poor judgement call on the part of RNS #1. She also stated RNS #1 resigned her position on 2/27/17. During an interview on 3/24/17 at 2:34 pm, the DON stated if an investigation revealed, or they felt abuse, neglect or mistreatment occurred, it is supposed to be reported within 24 hours. She stated reasonable cause would be injury/how the injury occurred, a statement from staff or a resident that abuse, neglect or mistreatment had occurred. She stated an investigation would be done to determine if the allegation was credible and then it would be discussed among the administrative team. She stated the 12/17/16 incident was first reported to administration (the AOR) via a voice mail message from CNA #3 which the AOR received on 12/19/16 upon her arrival at work. Discussed what staff had reported to RNS #2 the night of the incident; they were upset, and also that RNS #2 documented she assessed the resident and bruising was noted on the resident's arm. The DON stated if RNS #2 suspected abuse, neglect or mistreatment at the time the staff reported their concerns to her, she should have reported it at that time. She stated it appeared RNS #2 started the investigation on 12/19/16. During an interview on 3/27/17 at 1:19 pm, the AOR stated RNSs have the authority to remove an employee from the schedule if there is suspected abuse, neglect or mistreatment, but could also call the DON or ADON for guidance. She stated reasonable cause was the resident statement and bruising. She stated RNS #2 felt the incident had not been handled correctly by the staff involved but didn't think it was abuse, neglect or mistreatment. She stated the incident was reportable to the NYS DOH. She opted not to quote a timeframe in which abuse, neglect or mistreatment should be reported, stating they deferred to the Nursing Home Reporting Manual for the guidelines. During an interview on 3/28/17, RNS #2 stated RNS #1 reported the 12/17/16 incident to her when she came on duty that night at 11:00 pm. She stated she then went to LPN #1, CNA #1 and CNA #2 and spoke with each of them. She stated the bruising was reported to her at approximately 5:00 am. She stated she did not know if the bruising was from the resident being combative or if the bruises were caused by the resident's arm being held down. She stated RNS #1 did not follow the care plan for managing the resident's behavior. She stated she was unsure if abuse, neglect or mistreatment had occurred. She stated if she were unsure, she would start an investigation, which she did and would call the DON. She stated she sent an email to the DON (see 12/19/16 email). She stated if an occurrence of abuse, neglect or mistreatment were cut and dry, she would call the DON and immediately remove the staff from the schedule. She stated she was unsure of the exact timeframe in which alleged abuse, neglect or mistreatment must be reported. 10 NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedApril 12, 2017

1. Employees involved were remediated on reporting requirements at the time of the facility investigation. Report was made for Resident #1 to the Administrator of the facility and investigation initiated immediately upon receipt. Employees reporting did not identify at that time that the circumstances met the reasonable cause threshold, nor in follow up interviews did they believe it met the reasonable cause threshold.
2. All resident incident reports and complaints for the period of time from (MONTH) 1, (YEAR) to (MONTH) 31, (YEAR) will be reviewed to identify any potential situation which may meet the definition of reasonable cause to suspect abuse, neglect or mistreatment. No instances were noted.
3. Staff Education: All nursing staff will receive re-education on NYS reporting standards, specifically related to the responsibility to identify and report instances of abuse, neglect and mistreatment as outlined in facility policy. This will include the requirement which all staff have to intervene in any situation which may constitute abuse, neglect or mistreatment, even if intervening with a supervisory employee, and the mechanisms to do so.
5. Random selection of nursing staff will be selected monthly and provided a written test on facility policy related to resident rights, abuse prevention, and employee responsibilities related to reporting standards, etc. No fewer than 30 employees will be selected in months #1-3 (May - July); and 20 in months #4-6 (August - October). Audit plan to be reevaluated by the QAPI team after six months.
4. Responsible Party: Director of Nursing

FF10 483.10(b)(1)(2):RIGHT TO EXERCISE RIGHTS - FREE OF REPRISAL

REGULATION: (b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. (b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: June 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during an abbreviated survey (Case #NY 137), the facility did not ensure that each resident has the right to be free of interference, coercion, discrimination and reprisal from the facility in exercising his or her rights for one (Resident #1) of three (Resident #s 1, 8 and 9) residents reviewed. Specifically, the facility did not ensure Resident #1's right to be free from interference and coercion, when Resident #1 was abruptly awakened from slumber by facility staff, forcibly transferred into a wheelchair, and wheeled backwards toward the nursing unit. This was evidenced by: An undated Policy and Procedure titled NO FORCE Policy With Direct Care documented: We believe that the physical and psychological discomfort of being required to allow Activities of Daily Living (ADLs) to be performed works against our goals of promoting dignity and self-esteem through encouragement of maximum functional ability without making residents more dependent than they need to be. Resident #1: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her Minimum Data Set ((MDS) dated [DATE], indicated moderate cognitive impairment. There was no change in cognitive status compared to her 10/15/16 MDS. Observation of a security video on 2/16/17 revealed that on 12/17/16 at approximately 10:15 pm, facility staff Registered Nurse Supervisor (RNS) #1, Licensed Practical Nurse (LPN) #1, Certified Nursing Assistants (CNA) #1, and CNA #2 abruptly awakened Resident #1 from slumber on the lobby couch, forcibly transferred her into a wheelchair (w/c), and pulled the wheelchair out of the lobby. The incident lasted approximately 1 minute and 38 seconds. Prior to this incident, the security video revealed RNS #1 approaching the resident, and removing the resident's sweater which was covering her upper body like a blanket. RNS #1 stood in front of the resident for six seconds, before walking away. RNS #1 did not recover the resident with her sweater. The security video did not include sound. Review of the facility records included the following: -The document titled Your Rights as a Nursing Home Resident in New York State and Nursing Home Responsibilities dated (MONTH) 2010, documented nursing home residents had the right to be treated with dignity, respect and consideration at all times. It documented residents had the right for freedom of choice to make their own, independent decisions. It also documented the nursing home's responsibility was to protect residents from any kind of harsh and abusive treatment. -The NO FORCE Policy definition of direct care documented, The provision of ADLs with the assistance of staff. This would include bathing, dressing, toileting, dining, transfer and ambulation. The NO FORCE Policy purpose documented To provide ADL assistance in a dignified and humane manner to those individuals who have behavioral disturbances exacerbated by direct care. The section of the NO FORCE Policy titled Communication with the Cognitively Impaired documented Gently approach the person with an open, friendly, relaxed manner, establish eye contact to be sure that you have their attention and approach the person as an adult. -The Comprehensive Care Plan (CCP) for ADLs with a target date of 1/13/17, documented the resident was independent with a wheeled walker for transfers and ambulation. -The CNA (Certified Nursing Assistant) Care Card documented the resident was independent with walker for transfers and ambulation. -The Elopement/Wandering Risk Assessments completed from 11/14/15-12/20/16, classified the resident at low risk for elopement and wandering. -A Nurse's Note (NN) dated 12/17/2016, written by LPN #1 documented the LPN was aware the resident was sleeping in the lobby upon her arrival for the 10:00 pm-6:00 am shift. She was told by RNS #1 to get the resident back to her room. RNS #1, LPN #1 and CNA #'s 1 and #2 went to the lobby with a wheelchair (W/C) to get the resident. RNS #1 woke the resident up. The resident was angry and combative. The resident refused to go to her room, because her roommate was noisy and had the lights and TV on in the room and she was not going anywhere. RNS #1, CNA #1 and LPN #1 were able to maneuver the resident back to her room in the W/C. CNA #1 held the resident's right hand and RNS #1 held the resident's left hand and arm. -A NN dated 12/18/16, written at 11:57 am, by RNS #1, documented: The resident was sleeping in the lobby. She woke her up and asked why. The resident told her because her roommate was too noisy. RNS #1 told staff to get a W/C and bring the resident back to the unit. She documented CNA #1 and she picked the resident up under her arms and sat her in the W/C. The resident started yelling, I don't want to go to my room. She stated, I'm going to sit on the floor and attempted to do so. RNS #1 documented the resident did not sit on the floor and was assisted back to the W/C. LPN #1 pulled the W/C and CNA #1 and RNS #1 walked by the resident's side to try to prevent the resident from injuring herself as she hit at staff. -An email dated 12/19/16 at 5:15 am, from RNS #2 to the Director of Nursing (DON) regarding the 12/17/16 incident, documented staff that were involved in the incident with the resident had come to her with their concerns and told her they were very uncomfortable with the situation and it just felt wrong. She wrote that the resident did not want to stay in her room, because her roommate was noisy. She went to the main lobby and laid on the sofa. It was a normal behavior for the resident to do that. The staff would allow her time to calm down and after awhile, she could be redirected to her room. She documented the staff told her that RNS #1 did not want to allow the resident any time and wanted her back to her room immediately. She stated the witnesses reported to her that RNS #1 was very rough with the resident, grabbed her, forced her into a W/C and held her down. The resident told RNS #1 she was hurting her. There was significant bruising to her left arm. -A Formal Letter of Reprimand with a violation date of 12/17/16, and a Warning Date of 12/23/16, was reviewed with RNS #1. RNS #1 signed it on 12/24/16. It documented she did not follow the NO FORCE Policy, when she insisted on a resident being taken out of the lobby, and back to the unit when the resident made it clear she did not want to go. During a phone interview on 2/15/17 at 1:47 pm, regarding the 12/17/16 incident, CNA #2 stated she worked the 10:00 pm -6:00 am shift that night. She stated RNS #1 came to the unit and was not happy that the resident was alone in the lobby. She stated RNS #1 told her the resident needed to return to the unit, because she would be in the way of the cleaning staff. CNA #2 explained to RNS #1 that it was normal behavior for the resident to go to the lobby when upset with her roommate. RNS #1 stated the resident could not stay there so RNS #1, LPN #1, CNA #1 and CNA #2 went to the lobby with a W/C. She stated RNS #1 approached the resident when they entered the lobby and told her she needed to return to her unit. The resident stated, I'm not going down there, she (the roommate) has way too many lights on and it's too loud. CNA #2 stated RNS #1 told staff she could not stay in the lobby and at that point, RNS #1 and CNA #1 held the resident under her arms, stood her up and put her in the W/C. She stated the resident was distraught and fighting it. She stated they were hurting her arm. She stated the resident was resistant to having the W/C pushed. She had planted her feet on the floor so LPN #1 pulled the resident backward in the W/C to the unit. CNA #2 stated the NO FORCE Policy meant you could not do anything physically to a resident against their will. She stated RNS #1 violated the Policy. She stated the incident never should have gotten to that point. During a telephone interview on 2/16/17 at 1:37 pm, LPN #1 stated she worked the 10:00 pm -6:00 am shift on 12/17/16. She stated RNS #1 came to the unit approximately 10:30 pm and told her the resident was sleeping in the lobby. She stated CNA #1 and CNA #2 were with her when RNS #1 told them that the resident had to go back to the unit due to the cleaning people coming. She told them to go with her and bring a W/C. She stated they went to the lobby and approached the resident. She stated RNS #1 was the first to interact with her. She stated she did not recall RNS #1 saying anything to the resident at first, but removed the sweater from her face and sat her up. The resident was startled, upset and was pushing them away. The resident did not want to get up and stated she did not want to go with them; she was not going with them; and to leave her alone. LPN #1 stated the resident said that repeatedly. She stated RNS # 1 tried to stand her up to get her walker. The resident was still saying no. She stated CNA #1 then went on the other side of the resident and held her up while CNA #2 pushed the W/C under the resident. She stated the resident fought them when she was put in the W/C, because she did not want to be in a W/C. When wheeling the resident away from the sofa, the resident stood up and was resistant to being put back in the W/C. Once back in the W/C, the resident planted her feet on the floor to prevent the W/C from moving. RNS #1 turned her around and pulled the W/C backward out of the lobby. She stated that throughout the incident she kept saying she did not want to go back to the unit stating, I'm not going. RNS #1 then instructed LPN #1 to pull the W/C backward because the resident was still resistant to returning to the unit. RNS #1 had ahold of the resident's forearm and hand (could not recall if left or right) and was holding it down on the W/C armrest. The resident stated to her leave me alone, you're hurting me. She stated RNS #1 did not let go of the resident's arm and continued to hold it down on the W/C armrest. CNA #1 had a hold of the resident's other hand. She stated the resident was forced to go back to her room. During an interview on 2/16/17 at 3:55 pm, the Social Worker (SW) stated she had been the resident's SW for approximately two years. She stated she was made aware of the 12/17/16 incident upon her arrival at work on 12/19/16. She stated the only report she received was that the resident slept in the lobby and became angry when staff redirected her. The SW viewed the video of the incident. She stated the video was very disturbing. She also stated the resident was forcefully removed. During an interview on 2/16/17 at 4:30 pm, the Administrator on Record (AOR) stated she first learned of the 12/17/16 incident on 12/19/16, when she arrived at work and listened to her voice mail. She stated when she interviewed the resident about the incident, the resident stated, Look what they did to me, and I didn't fall. There were four of them on me. The AOR stated she was quite concerned when she viewed the video. She stated the NO FORCE Policy gave the resident the right to refuse. She stated you weigh the risks and benefits before action should be taken. She stated the way RNS #1 handled the situation was not the way she would have handled it. She stated when the resident refused to go back to her room, RNS #1 should have stepped back and re-approached. During an interview on 2/21/17 at 10:29 am, CNA #1 stated she worked 10:00 pm 6:00 pm on 12/17/16. She stated while she was getting report, RNS #1 came to the unit and told them (CNA #s 1 and 2 and LPN #1) the resident could not stay in the lobby. She told them to get a W/C and they all went to the lobby. She stated RNS #1 shook the resident awake and removed the sweater from her face. She told the resident as she was physically sitting her up that she had to get up. CNA #1 stated the resident was very angry and she stated she could not sleep in her room. Her roommate was too noisy. She stated she assisted RNS #1 with standing the resident because she was afraid the resident was going to fall. The resident was resistant to sitting in the W/C and absolutely did not want to go to her room. She stated RNS #1 told her you need to go; you need to go back to your room. She stated the resident attempted to get out of the W/C. RNS #1 and she put her back in the W/C. She stated RNS #1 held onto the resident's shoulder when she was put back into the W/C. Once back in the W/C, she was wheeled backward to the unit, because the resident was resistant to being wheeled forward. She stated she witnessed RNS #1 holding the resident's left arm down. CNA #1 stated she held the resident's right hand. She stated when they got to the resident's room she noted red marks on the resident's left hand and forearm (wrist area). She stated the resident was forced to return to the unit against her will. She stated she felt very uncomfortable with the incident. During an interview on 2/27/17 at 9:00 am, RNS #1 stated she worked on 12/17/16 from 7:00 am-11:00 pm. She stated she saw the resident laying on the sofa in the lobby approximately 10:15 pm and approached her. Her walker was in front of the sofa. She stated she woke the resident up. (MONTH) have called her name or touched her shoulder. She stated she may have asked her why she was there. She stated the resident told her to leave her alone So I did, I respected her request. She left the resident and went directly to the unit. She spoke to LPN #1 who told her she was aware the resident was in the lobby, because of issues with her roommate and they were keeping an eye on her. CNAs #1 and #2 heard the conversation. When asked why she felt the resident needed to leave the lobby even though the staff were aware she was in the lobby and were keeping an eye on her, she stated because she wasn't safe. She stated there wasn't enough staff on the 10:00 pm to 6:00 am shift to keep track of her. When asked if 15 minute checks were ever done on the 10:00 pm-6:00 am shift she stated yes. She was asked how that could be managed since she had just stated there wasn't enough staff to keep track of her. She stated you could have 15 minute checks for the resident; better yet, could have had somebody sit with her in the lobby. When she arrived back in the lobby with LPN #1, CNA #1, CNA #2 and a W/C, the resident was sleeping. Stated she woke her up, maybe called her name or touched her shoulder. She stated one of the CNAs (it was CNA #1) was on her right side. She does not remember if she assisted the resident to a sitting position. When she started to stand the resident up, she stated she took her under the arm. She stated CNA #1 may have assisted her. She stated after the resident was standing, she asked where she was going. RNS #1 stated somebody said To your room and the resident became angry and combative. She did not resist getting into the W/C. She stated LPN #1 turned the W/C to leave the lobby and resident lunged out of the W/C, took a couple of steps and stood between CNA #1 and RNS #1. She stated the resident said she would sit there on the floor and bent her knees to indicate her intent. Then CNA #1 and RNS #1 took the resident under each arm and put her back in the W/C. RNS #1 viewed the video. She stated the resident did not resist being pushed in the W/C, but kept her feet on the floor so they weren't able to push her forward and had to pull her backward. She stated the resident was wheeled backward into the hallway. When RNS #1 was asked why she was restraining the resident in the W/C with her hand on her shoulder as she was wheeling her from the lobby, she stated she wasn't restraining her. When asked Then why is your hand there, she stated, So she couldn't jump up from the W/C. She stated the incident escalated. She stated she wished somebody had said, maybe we should rethink this but nobody spoke up. She acknowledged there was a NO FORCE Policy at the facility. She stated it meant not to do something against a resident's will. When asked if she violated that policy she stated, It appears that I did by not stopping. She stated she should have stopped. It escalated and I should have stopped. During an interview on 3/8/17 at 2:02 pm, with the Physician's Assistant (PA) she stated she learned of the 12/17/16 incident on 12/21/16, when the Registered Nurse Manager (RNM) reported to her the resident had a Personal Watch on as a result of exit seeking behavior related to the 12/17/16 incident. She stated she was told the resident was forcefully and inappropriately removed from the lobby and had bruising. During the course of the interview, she viewed the security video of the incident. She stated it did not appear to her that the resident was exhibiting any exit seeking behaviors. She stated she was not happy to see how the situation was handled; it could have been handled differently. She stated she did not feel what staff did was appropriate on any level and she would have reported it to Administration. She stated it appeared RNS #1 was ready for the resident to be resistant by bringing three staff members and a W/C to the lobby with the intent to remove her from the sofa. She stated nobody should be forcefully removed from any situation unless in imminent danger and she did not feel there was imminent danger in this case. She stated the resident's dignity was violated. 10 NYCRR 415.3(c)(1)(iii)

Plan of Correction: ApprovedApril 12, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #1 received follow up counseling by psychological services 12/19/16; no [MEDICATION NAME] negative impacts noted. Employees involved received appropriate remediation/education.
2. All resident incident reports and resident complaints for the period of time from (MONTH) 1, (YEAR) to (MONTH) 31, (YEAR) were reviewed to identify any potential situation in which a resident?s right to be free from interference, coercion, etc. may have been compromised. No instances were noted.
3. Staff Education:
a. All nursing staff will receive re-education on resident rights, specifically related to the right to be free from interference and coercion; and the alternative methods of redirection if a resident resists intervention.
b. All facility RN?s received training and education materials on ?No Force? policies and on or about 2/20/17 on resident rights and the RN role in upholding facility standards.
4. Random selection of nursing staff will be selected monthly and provided a written test on facility policy related to resident rights and reporting responsibilities. No fewer than 30 employees will be selected in months #1-3 (May - July); and 20 in months #4-6 (August - October). Audit plan to be reevaluated by the QAPI team after six months.

Responsible Party: Director of Nursing

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: March 29, 2017
Corrected date: June 29, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during an abbreviated survey (Case # NY 137), the facility did not ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan (CCP), were provided by qualified persons in accordance with each resident's written plan of care for one (Resident #1) of four (Resident #s 1, 4, 5 and 6) reviewed. Specifically, Resident #1 sustained injuries when the care plan for managing her behavioral issues was not followed. This is evidenced by: Resident #1: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her Minimum Data Set ((MDS) dated [DATE], indicated moderate cognitive impairment. There was no change in cognitive status compared to her 10/15/16 Minimum Data Set (MDS). The Comprehensive Care Plan (CCP) for ADLs with a target date of 1/13/17, documented the resident was independent with a wheeled walker for transfers and ambulation. The CNA Care Card documented the resident was independent with walker for transfers and ambulation. The CCP for verbally abusive behaviors implemented on 9/18/15 and still active, documented the resident tolerated one person at a time, needs and has personal space. When the resident became agitated to intervene before the agitation escalated; guide away from source of distress; engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. During an interview on 2/16/17 at 4:30 pm, the Administrator on Record (AOR) stated she first learned of the 12/17/16 incident on 12/19/16. She stated when the resident refused to go back to her room, Registered Nurse Supervisor #1 (RNS) should have stepped back and re-approached. During an interview on 2/22/17 at 3:18 pm, RNS #2 stated when CNA #2 spoke with her the night of the 12/17/16 incident, she told RNS #2 that she requested RNS #1 to give the resident some time to calm down and then re-approach her. She stated RNS #1 said no. During an interview on 2/23/17 at 2:17 pm, the DON stated she viewed the video of the 12/17/16 incident of RNS #1 removing the resident from the lobby and could see the resident was becoming angry and her anger was escalating. She stated RNS #1 should have handled the situation differently. She stated RNS #1 had bad judgement. She stated the resident's care plan was not followed and could she have done something differently? Absolutely. During an interview on 2/27/17 at 9:00 am, RNS #1 stated she worked on 12/17/16 from 7:00 am- 11:00 pm. She stated she saw the resident laying on the sofa in the lobby approximately 10:15 pm and approached her. Her walker was in front of the sofa. She stated she did not know the resident's ambulatory status at the time of the incident. She looked it up the next day in the care plan. She stated she took the W/C to the lobby because it was a long walk back to the unit. She stated she sat the resident up and with her hand under the resident's armpit, stood her to transfer her to the W/C. She stated she did not know why she did that because the resident was ambulatory (after she stated she did not know the resident was ambulatory at the time of the incident). She stated she did not look at the resident's care plan prior to the incident. Therefore, she was not aware of the approach to take when the resident was agitated. During an interview on 3/10/17 at 2:16 pm, CNA #2 stated she had told RNS #1 the best approach to use with the resident prior to going to the lobby. She stated RNS #1 disregarded her. During an interview on 3/28/16 at 10:44 am, RNS #2 stated based on the resident's care plan for managing behaviors, RNS #1 did not follow it. 10 NYCRR 415.11(c)(3)(ii)

Plan of Correction: ApprovedApril 12, 2017

1. Resident #1 Care Plan and care card was reviewed and found to be appropriate. RNS#1 was provided remediation on requirement that the plan of care be consulted prior to providing care, and counseled for her actions.
2. All residents (100%) were reviewed to assure a comprehensive care plan and care card is in place and accessible to staff.
3. All Registered Nurses (RNs) currently employed and upon new hire will receive education specific to the requirement that the plan of care or care card, or a primary care giver who is fully aware of the plan of care, be consulted prior to providing direct care to a resident. Facility policy related to the Plan of Care as the guide to resident care will be reviewed and updated if necessary.
4. Random selection of no less than 50% of all employed RNs will be interviewed by the QAPI coordinator on a monthly basis for six months to identify their knowledge of the use of the plan of care and the requirement that it (or knowledgeable employee) be consulted prior to delivery of patient care. Audit plan to be reevaluated by the QAPI team after six months.
Responsible Party: Director of Nursing