Sapphire Nursing at Meadow Hill
September 20, 2018 Complaint Survey

Standard Health Citations

FF11 483.95(c)(1)-(3):ABUSE, NEGLECT, AND EXPLOITATION TRAINING

REGULATION: §483.95(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on- §483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. §483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property §483.95(c)(3) Dementia management and resident abuse prevention.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 20, 2018
Corrected date: November 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during an abbreviated survey (NY 452), it was determined that the facility did not provide documented evidence that training and education was provided to the staff, families and visitors prohibiting the use of any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings of residents that are demeaning or humiliating. Specifically, a resident's (#1) picture with identifying personal information and condition was shared on social media platform by a family friend of another resident (#4). The facility's Abuse Prohibition Manual of (MONTH) (YEAR) under the section Photographic and Audio Devices, Staff Use stated that the facility does not permit photographing of any kind or use of audio recording devices, unless prior written permission is obtained from the resident / responsible party and facility management. This policy did not include prohibition of such from families and visitors. The training component of this policy stated that the facility will train employees, through orientation and ongoing sessions on issues related to abuse and prohibition practices. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Significant Change Minimum Data Set (a resident assessment tool) of 7/27/18, the resident had severe cognitive impairment for daily decision making; required extensive assistance of 1-2 persons with most aspects of activities of daily living; had one Stage 2 pressure ulcer and was at risk for developing pressure ulcers. The admission agreement packet that is provided to the families and residents upon admission contained a provision prohibiting the use of photographic and audio devices by residents, family and visitors. It stated that the facility will educate residents and family members about this policy upon admission and thereafter as needed. There was no documented evidence that the family of Resident #1 was educated on this policy contained in the admission packet upon admission. There was no signed evidence that the family, including the Health Care Proxy, Power of Attorney, next-of-kin or designated representative had acknowledged, agreed or accepted receipt of this admission agreement and had the opportunity to ask questions pertaining to the prohibition against the use of photographic devices. The Intake Information of 9/17/18 indicated that the resident #1's picture was posted in a social media platform that included the resident's name and room number. The picture showed the resident wearing a diaper; the legs and feet were exposed showing black discoloration; and a blue protective cover placed under the legs. The resident was noted to be wearing a white tee shirt with a small portion of his abdomen showing and there was no bed sheet covering the resident. The facility conducted an investigation of the incident on the same date, 9/17/18, and concluded that the resident's photos and video were posted on social media by a friend of the resident #4's daughter. It was revealed that the friend took unauthorized and compromising photos and videos of resident #1 without knowledge of his family, the facility or the facility staff. An onsite investigation was conducted on 9/20/18 at 9:45 AM. Upon entrance to the facility, a signage was observed posted on a bulletin board located in the lobby area that contained numerous printed materials. This signage was not prominently or conspicuously displayed. Interviews were conducted on 9/20/18 from 10:00 AM to 2:00 PM which included 4 Certified Nurse Aides, 3 Licensed Practical Nurses and a Registered Nurse. During these interviews, the staff stated that they did not have any formal in-service training regarding the prohibition on the use of photographic devices on residents without consent. They all stated that following the incident of 9/17/18, the Director of Nursing (DON) met with the staff in the units in a huddle to discuss the incident and the future actions to take to prevent a reoccurrence. No staff member that were interviewed, stated or mentioned about the signage being posted in the lobby regarding the prohibition of photographic devices as part of the training. There was no documented evidence provided, upon request, of an attendance sheet with the date or description of the training prior to 9/17/18 of how this incident could have been prevented to the extent possible. The DON and the administrator were interviewed on 9/20/18 at 10:45 AM. The DON stated that she went to individual units to advise the staff what procedure to follow if they see anyone taking pictures or videos of residents other than their family members. The DON was unable to provide at the time any documented evidence that ongoing training, prior to the incident of 9/17/18, had taken place. The facility administrator was asked about the corrective actions the facility had taken to protect the identity and privacy of all residents. He stated that they have not done one thing. The administrator further stated he contacted and was awaiting his corporate counsel regarding this issue and what further actions to take. This was 3 days after the incident occurred. He further stated that he contacted the state and police agencies involved and have prohibited the person(s) responsible for taking unauthorized pictures of resident #1. 415.4(b)

Plan of Correction: ApprovedOctober 15, 2018

F943
415.11(c)(1)
483.95(c)(1)-(3) Abuse, Neglect, and Exploitation Training
1. The facility increased appropriate signage as visible, prominent, and conspicuously displayed in multiple areas in the building, to include the main entrance, hallways, elevators and other locations. The facility immediately initiated Abuse, Neglect, and Exploitation Training for all employees to include the use of Photographic and Audio Devices, and ongoing.

2. The Administrator/designee reviewed and revised current policy of Abuse, Neglect, and Exploitation to include prohibiting use of Photographic and audio Devices. The facility Admission Agreement was reviewed for the process of notification to resident and family for prohibiting photographic and audio devices was reviewed. Notification to the resident/new admission was added in the nursing assessment to include prohibiting of photographic and audio devices.

3. The Nurse Educator/designee will in-service all employees on Abuse, Neglect, and Exploitation policy to include Use of Photographic and Audio Devices for employees, resident, family and visitors, and the use of signage throughout the facility as designated.

4. The Administrator/designee will audit for visible, prominent and conspicuous display of signage regarding use of photographic and audio devices monthly x 3 months. The Administrator/designee will audit for the completion of Admission Agreement, to include acknowledgement of the facility policy for Use of Photographic and Audio Devices, weekly x3 months, then monthly x3 months.
The Administrator will be responsible with compliance.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 20, 2018
Corrected date: November 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during an abbreviated survey (NY 452), the facility did not ensure that care and services were provided for 1 of 4 residents (#1) reviewed for privacy and dignity. Specifically, the facility did not develop a person-centered care plan with measurable objectives, timeframes with appropriate interventions to address a resident's behavior of disrobing and removing blankets and sheets that put the resident at risk for exposure. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Multiple resident observations were made during the survey, and the following was observed: Resident #1 was observed at 12:30 PM. He was awake and disoriented to name, place and time and did not respond verbally. He was sitting in a geriatric chair in the dayroom amongst other residents. He was dressed in his personal clothes and with an oxygen device in place. He was calm and not in any distress. The resident's wife was standing next to him and was grooming him and combing his beard. At 2:30 PM, Resident #1 wounds were observed. The wounds to the sacrum and right buttock had a slough formation on the wound bed and edges and measured approximately 7 cm wide and depth could not be determined. The surrounding skin had no [DIAGNOSES REDACTED] and was intact. The right shin wound was healed. The left toes, foot, and lower leg are noted with eschar and blackish color discoloration to the toes and advancing to the foot and lower leg. The nurse who was present at the time of this observation maintained the resident's privacy. The privacy curtain was pulled, and the resident was not visible from the hallway during observation of the sacral area wound. Resident #4 was observed at 12:45 PM in room [ROOM NUMBER]. He was awake and disoriented to place and time. He was sitting in his room, on his bed, dressed in his personal clothes, and watching television. The care plan for non-compliance was initiated on 7/20/18 and documented that the resident exhibited behaviors including taking oxygen off, disrobing, removing blankets and sheets, and restless movements in bed. The goal of this care plan documented that the resident will comply with all cares over the next 90 days. The interventions listed to attain this goal included, assess resident's ability to understand and adhere to therapeutic regimen, identify and acknowledge resident values/ belief, offer personal choices in decision making, educate resident and family on importance of adhering to therapeutic regimen, re-approach when combative, offer diversional activity, 1:1 conversation, and involve the resident's wife. The Significant Change (SC) Minimum Data Set (MDS; a resident assessment tool) of 7/27/18 indicated the resident had severe cognitive impairment for daily decision making; required extensive assistance of 1-2 persons with most aspects of activities of daily living including dressing, toilet use and personal hygiene. This MDS further indicated that the resident did not exhibit any mood or behavioral symptoms. A Certified Nursing Aide (CNA #1) was interviewed on 9/20/18 at 10:55 AM and she stated at the time when the resident's picture was taken by a friend of Resident #4's daughter and was posted on social media, the resident's bedsheets were pulled back, exposing the resident's diapers and lower extremities up to the thigh. The Director of Nursing (DON) was interviewed on 9/20/18 at 11:00 AM and did not provide any indication of the resident's combative behavior, disrobing, or removing blankets and sheets. The assigned Licensed Practical Nurse (LPN #1) was interviewed on 9/20/18 at 12:00 PM and stated that on 9/17/18 after the wound rounds, she left a blue protective cover on the resident's legs and then exited the resident's room to obtain the wound dressing supplies outside the resident's room. Review of resident #1's picture posted by the friend of resident #4's daughter on a social media platform showed the resident's name and room number. The picture showed the resident wearing a shirt and diaper, his legs and feet were exposed showing skin discoloration. A blue protective cover was placed underneath the resident's lower extremities. The blanket and sheet could not be distinguished. The facility conducted an investigation of the incident on the same date, 9/17/18, and concluded that a friend of resident #4's daughter took unauthorized and compromising photos and videos of resident #1 while in bed without knowledge of the facility or its employees and posted it on a social media platform. The problems/ needs identified on the above care plan did not reflect the moods and behaviors identified in the SC MDS which included rejection of care and treatment (removing oxygen) and disrobing/ removing blankets. The interventions listed were not appropriate to the resident's identified problems, needs, and cognitive level. It did not include specific interventions to address the problems related to disrobing or removing blankets or sheet to maintain the resident's privacy and dignity to the extent possible. 415.11(c)(1)

Plan of Correction: ApprovedOctober 15, 2018

F656
483.21(b)(1) Develop/Implement Comprehensive Care Plan
1. The Director of Nursing reviewed and revised affected resident?s (#1) Comprehensive Care Plan to develop/implement a person-centered care plan with measurable objectives, timeframes with appropriate interventions that address resident?s (#1) behavior of disrobing and removing blankets and sheets that put the resident at risk for exposure.

2. All other residents with behavioral triggers placing them at risk for exposure and the potential for being affected were identified by the Interdisciplinary Team and the individual resident Comprehensive Care Plan will be reviewed and revised as applicable to ensure a person-centered care plan with measurable objectives, timeframes with appropriate interventions to address the resident behavior that puts the resident at risk for exposure.
3. The Nurse Educator/designee will re-educate the Interdisciplinary Team on development and implementation of person-centered comprehensive care plans that include measurable objectives, timeframes with appropriate interventions to address a resident?s behavior that puts the resident at risk for exposure.
4. The Director of Nursing Services/designee will audit those residents identified with behavioral triggers placing them at risk for exposure and the development and implementation of the individual resident comprehensive care plan monthly x3 months, then quarterly, or until 100% compliance. The audit findings will be reported monthly to QAPI Committee for review.
The Director of Nursing Services will be responsible with compliance.