Chautauqua Nursing and Rehabilitation Center
September 18, 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: September 18, 2017
Corrected date: November 13, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Abbreviated Survey (Complaint #NY 605) completed on 9/18/17, it was determined that the facility did not report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within five working days of the incident. One (Resident #1) of four residents reviewed for accidents [MEDICAL CONDITION] three occasions while smoking and the incidents were not reported or not reported timely to the State Survey Agency. The finding is: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS - a resident assessment tool) dated 8/19/17 revealed the resident is understood, understands and is cognitively intact. Review of the current Care Plan Activity Report (comprehensive care plan) revealed a focus area for Smoking - Non Responsible Smoker was initiated 5/4/16. The Care Plan Activity Report documented that the resident was a former smoker; he resumed smoking after admission to the facility; and is often noncompliant with wearing a smoking apron. Review of the current Resident Nursing Instructions (certified nurse aide (CNA) care plan) printed 9/8/17 revealed the section for Safety implemented 4/28/17 documented that the resident was given a Wander Guard (device to detect wandering). An intervention dated 6/16/17 documented that the resident Must wear smoking apron and use smoking device when smoking- put in wheel chair bag. (MONTH) not smoke without staff supervision three-five feet away. Wander guard on wheel chair. a.) Review of an Incident/Accident Report, completed by a Registered Nurse, dated 1/2/17 at 3:30 PM revealed Resident #1 was outside smoking without wearing a lap protector (smoking apron); the end of his cigarette fell on his leg; and he sustained a 1 cm (centimeter) round superficial blister on his right thigh. Review of physician's orders [REDACTED]. Review of a Nursing Progress Note dated 1/2/17 at 4:07 PM revealed Aide notified nurse that resident came back from smoking outside and had a 1 cm/ 2 cm burn on his upper thigh. Resident stated he didn't have the lap protector on. Family and Supervisor notified. Review of an Online Submission form dated 3/17/17 at 4:52 PM revealed the incident (burn) that occurred on 1/2/17 at 3:30 PM was reported to the New York State (NYS) Department of Health (DOH). b.) Review of an Incident/ Accident Report, signed by an RN and the Director of Nursing (DON), dated 3/25/17 at 2:45 PM revealed that the resident reported that ashes may have landed on his shirt, while he was smoking outside by the back door. The Report documented that the resident had a 1/2 cm area on the outer aspect of of the right forearm. The area was cleansed with normal saline and [MEDICATION NAME] (antibiotic ointment) was applied. A Nursing Progress Note dated 3/25/17 at 11:06 PM documented that as 3:00 PM-11:00 PM staff were entering the building, Resident #1 was sitting outside near the back-door smoking. The resident asked the staff to look at his shirt because he thought smoke ashes may have landed on his shirt. The Progress Note documented that the resident had a ½ cm round area on the outer aspect of the right lower arm and there was a burn hole on his jacket. Review of information provided by the facility regarding the Incident/Accident that occurred on 3/25/17 revealed no documented evidence that the incident was reported to the NYS DOH. c.) Review of an Incident and Accident Investigation Report dated 3/27/17 at 8:30 PM revealed the resident stated he burned his chest with a cigarette and he sustained a 0.3 x 0.3 blister. The Report documented that the resident was out on pass, without his smoking vest. Review of a Nursing Progress Note dated 3/29/17 revealed documentation related to Accident/Incident IDT (Interdisciplinary Team) Conclusion of 8:30 PM 3/27/17. The Progress Note documented that the Resident was outside with another resident smoking and burned self from ashes; burn to sternum. The skin is [DIAGNOSES REDACTED]tous (reddened) and not broken. Review of information provided by the facility for the Incident/Accident that occurred on 3/27/17 revealed no documented evidence that the incident was reported to the NYS DOH. During an interview on 9/8/17 at 11:20 AM, the resident stated he did burn himself with a cigarette when he was out on pass with a friend. He stated he went to flick the cigarette out of his mouth and it bounced off the ashtray onto his shirt in a folded area. His friend attempted to look for it but could not find it. When he returned to the facility that night, it was his CNA (certified nurse aide) who found it in his shirt. The resident said he had a blister in the area where the cigarette was located. He stated that he has several burn marks from cigarettes. During an interview on 9/15/17 at 10:07 AM, the DON stated I don't know what happened to the accident report I filed with the state for the 1/2/17 incident. I did file it right away but apparently, it didn't go through. I thought I had submitted it in (MONTH) (2017) when the incident occurred and found out later it never went through. I did not get a confirmation number because I didn't know I needed one. We found out that it wasn't submitted through a mock survey done here at the facility. I then resubmitted on 3/17/17 and this time received a confirmation number. The other two incidents on 3/25/17 and 3/27/17 were not submitted because the skin was not broken. I discussed both with the administration team and we felt it did not need to be reported. During a telephone interview on 9/18/17 at 3:30 PM, the Administrator stated the incident on 1/2/17 was reported to the DOH, but the DON never received the confirmation number. The incidents that happened on 3/25/17 and 3/27/17 were before the new incident manual came out. I believe the old manual doesn't state that [MEDICAL CONDITION] to be reported. Review of the current NYS DOH Nursing Home Incident Reporting manual dated 8/2016 revealed At least one of the following elements must be present for an incident to be reportable to the NYS DOH: Accident resulting in a burn to the body surface. Review of a facility policy and procedure (P&P) entitled Abuse Reporting and Facility Incident Reporting dated 7/2017 revealed any alleged violations involving mistreatment, neglect or abuse, including injuries of an unknown source, misappropriation of resident property, and exploitation will be reported to the appropriate involved parties and state agencies. The P&P documented One of the following elements is needed for report to the DOH (Department of Health): Accident resulting in a burn to the body surface. 415.4(b)(4)

Plan of Correction: ApprovedOctober 12, 2017

I. Corrective action for resident found to have been affected by the deficient practice:
The Abuse Reporting Policy and Facility Incident Reporting Policy were reviewed by the Management Team with specific focus on non-serious injuries and revised as necessary.
Completion: 9/15/2017
Responsibility: Director of Nursing
A review and in-service of the NYSDOH Nursing Home Incident Reporting Manual (8/16) was conducted for all staff involved in reporting decisions.
Completion: 11/13/2017
Responsibility: Director of Nursing
II. Identification and corrective action for residents having the potential to be affected by the same deficient practice:
Review of all other incident reports from 1/1/17 forward which was completed on 9/30/17 that were not reported to the State Survey Agency to ensure the requirements for reporting were followed correctly per the Nursing Home Incident Reporting Manual (8/2016) regarding non-serious injuries required to be reported within 5 days. On review of 10 months of reports, no other issues were identified.
Completion: 9/30/17
Responsibility: Director of Nursing
III. The systemic changes to ensure that the deficient practice does not recur:
The facility will use an audit tool that will be a part of all resident incident reports beginning 11/1/17 in order to determine if an incident is reportable to the Department of Health. This process will continue until six (6) consecutive months of 100% accuracy has been achieved. Any report identified to be reported to the Department of Health will be reviewed by the Administration and reported to the NYSDOH by the Director of Nursing or Administrator.
Completion: 11/13/2017
Responsibility: Director of Nursing
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
The identified issue of timely incident reporting to the State Survey Agency will be incorporated into the QAPI Program to ensure that the deficient practice does not recur and confirm the effectiveness of the education on the NYSDOH Nursing Home Incident Reporting Manual (8/2016). Results of these audits on our compliance with reporting to the State Survey Agency will be reported during each QAPI meeting until six (6) consecutive months of 100% accuracy has been achieved to determine the effectiveness of the process and education.
Completion: 11/13/2017
Responsibility: Director of Nursing