Park Nursing Home
December 19, 2018 Complaint Survey

Standard Health Citations

FF11 483.12(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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. §483.12(c)(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: December 19, 2018
Corrected date: February 13, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during an abbreviated survey (NY 149 & NY 411), the facility did not ensure that two Resident-to-Resident altercations were reported to New York State Department of Health (NYSDOH) in a timely manner. This was evident in 4 out of 6 residents sampled (Residents #1, #2, #3, & #4). Specifically, incident #1 took place on 08/17/2018 and the facility reported it to NYSDOH on 10/01/2018. Incident #2 took place on 09/04/2018 and the facility reported it to NYSDOH on 10/04/2018. The findings include: The facility revised Policy and Procedure on Abuse Prevention, dated 10/22/2018, stated that it is the policy of this facility to report to the proper authorities within the prescribed timeframe all alleged violations related to abuse. The policy also stated that the facility has five working days to complete the investigation. The investigative findings will be reported to Administrator and as indicated to the NYSDOH. Resident #1 was admitted to facility on 12/20/2017 with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS, an assessment tool) dated 6/17/2018, documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 15/15, indicating cognitively intact (00-07 Severe Impairment, 08-12 Moderate Impairment & 13-15 Cognitively Intact). Resident #2 was admitted to facility on 12/14/2012 with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #2 had a BIMS score of 10/15, indicating moderate impairment in cognition. Resident #3 was admitted to facility on 12/19/2017 with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #3 had a BIMS score 12/15, indicating moderate impairment in cognition. Resident #4 was admitted to facility on 12/20/2017 with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #4 had a BIMS score of 11/15, indicating moderate impairment in cognition. Review of the facility Investigation Summary (incident #1) dated 8/17/2018, revealed that Resident #1 and Resident #2 was in an altercation in the dining room. The facility investigation the incident and reported it to NYSDOH on 10/01/2018. Review of the facility Investigation Summary (incident #2) dated 09/04/2018, revealed that Resident #3 and Resident #4 were in an altercation in the smoking areas of the backyard. The facility investigated the incident and reported it to NYSDOH on 10/04/2018. The Director of Nursing was interviewed on 11/23/2018 at 3:30 PM and stated that she was responsible for investigating and reporting all alleged incidents of Resident-to-Resident abuse within 5 working days to the NYSDOH. During a Quality Assurance review, she discovered that the incidents were not reported and she reported them to the NYSDOH. The Administrator was interviewed on 12/19/2018 at 12:44 PM and stated that all incidents regarding abuse must be reported to the NYSDOH within 5 working days. He stated that the DNS was responsible for investigation and reporting the incidents. 415.4(b)

Plan of Correction: ApprovedJanuary 4, 2019

1) Immediate Corrective Action for Resident affected:
i. An Ad -Hoc meeting was held on 10/3/18 with the Administrator, Director of Nursing Services (DNS) and Ownership/Designee. The meeting was held to discuss the concerns identified by the DNS that investigations of Resident to Resident Altercations and Reportable Occurrences had not been reported to the Department of Health (DOH) by the DNS in a timely manner.

ii. The Administrator and Director of Nursing also received an educational counseling on 10/3/18 by Ownership/Designee for failure to ensure that Resident to Resident investigations are reported to the DOH in a timely manner.
iii. The Administrator and Director of Nursing received an educational counseling on 1/3/19 by Ownership/Designee for failure to ensure compliance with Federal Regulation 483.12 (c)(1)(4) F Tag 609. Additionally, the counseling addressed the failure to follow the facility policy on Abuse Prevention.
iv. Educational counselling on file for validation
2) Identification of other Residents:
i. The facility respectfully states that all residents have the potential to be affected by the deficient practice.
ii. The Ownership/Designee has reviewed all the Resident to Resident altercations since (MONTH) (YEAR) through (MONTH) (YEAR). All reportable incidents have been reported to the NYS Department of Health.
iii. No other identified issue.
3) Systemic Changes made so the deficiency will not reoccur:
i. The Administrator, DNS and Ownership/ Designee have reviewed the facility?s P&P Abuse Prevention. No revisions necessary.
ii. The ownership/Designee will in-service the administrator , DNS & ADNS regarding the P&P on Abuse Prevention. The focus will address:
? Completing Resident to Resident and Accident/Incident Reports in a timely manner.
? All Residents to Resident Altercations/Reportable Incidents to be reported to Administration, DNS/Designee and Ownership Designee at time of occurrence.
? Timely reporting to NYS DOH as per regulations.
? Lesson Plan and In-service records will remain on file for validation.
4) Monitoring of the Corrective Action/Quality Assurance:
i. The Ownership/Designee has developed an audit tool to monitor the facility?s compliance with the timely Reporting of Resident to Resident Altercations and Reportable Incidents as per P/P.
ii. The audit will be completed by the Administrator/Designee for all Resident to Resident Altercations /Reportable Incidents weekly x 4 weeks, 20% monthly x 2 and quarterly thereafter.
All audit findings will be reported to the QA Committee for follow-up and input as needed.
5) Responsibility:
Administrator