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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 11, 2024
Corrected date: January 26, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during abbreviated survey (NY 123), the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 3 of 4 residents (Resident #1, #3, and #4) reviewed and for an additional 6 unidentified residents. Specifically, facility investigations did not identify concerns related to: -Resident #2, a cognitively impaired resident, was touched on their breast by Resident # 1. Two weeks later, Resident #2 was documented as having Resident #1 rub their genitals against them. There was no documented evidence Resident #2 was assessed timely, no evidence the provider and the resident's family were notified timely and interventions to protect Resident #2 and other vulnerable residents were not implemented timely. - Resident #4, a cognitively impaired resident had their back and buttocks rubbed by Resident # 1. - Resident #1 had sexually inappropriate behaviors towards unidentified residents documented in their medical record on 6 occasions (including kissing 2 residents and exposing self and masturbating in front of 4 residents). The 6 residents involved were not identified and there were no corresponding investigations related to the incidents. Findings include: The undated facility policy, Abuse Prevention and Reporting, documented all residents would be kept free from abuse and neglect. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment which resulted in physical harm, pain, or mental anguish. Sexual abuse included, but was not limited to, sexual harassment, or sexual assault. The facility would immediately take steps to ensure resident safety and provide medical attention when necessary. They would secure statements from all parties involved. Social Services would be contacted to interview all parties involved. 1) Resident #2 had [DIAGNOSES REDACTED]. Resident #1 had [DIAGNOSES REDACTED]. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury, The 1/9/2024 at 9:44 PM Incident Report by Licensed Practical Nurse #4 (Assistant Director of Nursing), documented Resident #1 was seen touching Resident #2's breast around mealtime and Resident #2 appeared unaware of incident and was without injury. Immediate measures taken included redirection which was effective. The physician was notified on 1/10/2024 at 2:10 PM and family notified on 1/11/2024 at 9:24 PM. The 1/9/2024 at 10:11 PM Licensed Practical Nurse #16 progress note documented an aide reported Resident #1 was touching Resident #2's breast outside of clothing during breakfast. The residents were immediately separated, and Resident #2 did not appear aware of incident. Resident #1 was educated about inappropriate behavior and kept to other side of the dining room. There was no documented evidence Resident #2 was assessed immediately following the incident. There was no documented evidence Resident #2's family, and the medical provider were notified of the incident on 1/9/ 2024. There was no documented evidence Resident #1 was assessed immediately following the incident. There was no documented evidence Resident #1's family, and the medical provider were notified of the incident on 1/9/ 2024. The 1/22/2024 at 6:05 PM note completed by Licensed Practical Nurse #14 documented Resident #1 was seen rubbing their genitalia on Resident # 2. As soon as Resident #1 noticed they were seen, they stopped and headed out of dining room. The 1/22/2024 at 8:30 PM Incident Report recorded on 1/23/2024 at 8:26 PM by Licensed Practical Nurse #8 documented a nurse reported that Resident #1 had Resident #2 touch their genitals. The residents were immediately separated, Resident #1 was placed on 15-minute checks and the incident was reported to the Department of Health. The 1/22/2024 at 8:30 PM Licensed Practical Nurse #8 note documented the nurse reported earlier in the shift, Resident #2 was touching Resident #1's private areas. There was no documented evidence Resident #2 was assessed immediately following the incident. There was no documented evidence Resident's #1 and #2's family or medical provider were notified of the incident on 1/22/ 2024. 2) Resident #4 had [DIAGNOSES REDACTED]. Resident #1 had [DIAGNOSES REDACTED]. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury. The 5/20/2023 at 10:28 PM Licensed Practical Nurse #9 progress note documented it was reported to them Resident #1 had engaged in inappropriate sexual behavior with a resident on the North Unit (grabbing their buttocks with both hands). It was also reported the resident was still on the North side, near the other resident, because attempts to redirect Resident #1 back to the South Unit were in vain. The licensed practical nurse managed to get the resident back on the South Unit at dinnertime when the resident attempted several times to return to the North Unit. At that point they instructed the unit assistant to be 1:1 with the resident to avoid any further behaviors. The 5/20/2023 Incident Report recorded on 5/24/2023 by Registered Nurse #10 documented at 1:20 PM, Resident #1 was observed hugging Resident #4 and rubbing their hand up and down Resident #4's back and buttocks. An assessment was completed and there were no marks on Resident # 4. The residents were immediately separated. Resident #1 was also educated to keep their hands to themselves. Resident #1 was redirected and placed on 15-minute checks. The 5/20/2023 nursing schedule did not document Registered Nurse #10 on duty on all 3 shifts the day of the incident. The 5/23/2023 at 11:10 AM Registered Nurse #10 note documented the resident had no recollection of the incident on 5/20/2024 when another resident forcibly hugged them and no indication of psychological harm. There was no documented evidence Resident #4 was assessed immediately following the incident. There was no documented evidence Resident #4's family and medical provider were notified on 5/20/ 2023. 3) Unidentified Residents The 8/13/2023 at 9:30 PM Registered Nurse #19 progress note documented Resident #1 remained on 30-minute checks throughout shift. There were no issues noted until 9:30 PM when Resident #1 was found with their pants down in the dining room demonstrating inappropriate sexual behavior while another resident was present at a distant table. Resident #1 was encouraged to return their room and would continue 30-minute checks. The 10/30/2023 at 9:29 PM Licensed Practical Nurse #15 progress note documented Resident #1 was in dining room with others present when they pulled their pants down exposing self and was rubbing their genitals. The resident was educated that the behavior was not acceptable. The 1/23/2024 at 10:00 PM Licensed Practical Nurse #8 progress note documented while walking to the nursing station, they observed Resident #1 take their genitalia out of their pants in proximity of a resident. The 1/24/2024 at 7:16 PM Licensed Practical Nurse #1 progress note documented Resident #1 was in the dining room with another resident who was asleep at the next table. Resident #1 changed chairs to be closer to the sleeping resident, pulled their pants down, exposed themself and was touching their genitals. The 7/29/2024 at 3:02 PM former Director of Nursing #20 progress note documented Resident #1 wheeled up to another resident and kissed them on the mouth. Staff immediately intervened and separated residents. There was no documented evidence the facility investigated any of the incidents to identify the other residents present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other residents were impacted by Resident #1's inappropriate behavior. The 10/12/2024 at 3:06 PM Licensed Practical Nurse #4 (Assistant Director of Nursing) progress note documented a housekeeper reported they observed Resident #1 kiss another resident in the dining room. Staff intervened, the residents were easily redirectable and there were no signs of emotional distress. Resident #1 was placed on 15-minute checks for 3 days. The corporate Director of Nursing was updated. The supervisor was contacting family and the provider. The 10/12/2024 at 10:48 PM Registered Nurse Supervisor #7 progress note documented they were notified Resident #1 attempted to kiss another resident in the dining room and the residents were separated. The Director of Nursing and provider were notified. Resident #1 placed on 15-minute checks. No signs and symptoms of distress. The 10/12/2024 Incident report, recorded on 11/7/2024 at 4:34 PM by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed to have kissed a resident of the opposite sex. There was no documented evidence the incident was investigated timely and no documented evidence the residents were assessed on 10/12/ 2024. During a telephone interview on 11/29/2024 at 9:36 AM, Licensed Practical Nurse #15 stated an incident report was completed when there was something out of the normal that needed to be noted like an injury of unknown origin, resident to resident abuse and elopement. Sexually inappropriate behaviors would also require an incident report. If other residents were exposed to a resident's inappropriate sexual behavior, they needed to be assessed and that was something they could not do as a licensed practical nurse. Sometimes there was a registered nurse on duty who could assess though not always. On 10/30/2023, they did not recall if they completed an incident report however one would have been required. They did not recall who the other residents were present at the time of the behavior. They stated if there was a supervisor in the building on 10/30/2024, they would have notified them and did not recall if they notified. During a telephone interview on 11/29/2024 at 10:23 AM, Licensed Practical Nurse #1 stated the purpose of an incident report was to document falls, resident to resident abuse, as well as any resident-to-resident contact if there was a chance of injury. Sexually inappropriate behaviors also required an incident report and assessment by the registered nurse. They reported incidents to the supervisor and if the supervisor was not a registered nurse, then the Assistant Director of Nursing was notified, and the Assistant Director of Nursing would find a registered nurse to come to the building to assess. Licensed Practical Nurse #1 was responsible to obtain staff statements and notify the provider and family. If residents were exposed to inappropriate sexual behaviors, they would monitor the residents, note any concerns, and speak with them to make sure they were not affected. On 1/24/2024, 15-minute checks were not effective, and the resident continued with sexually inappropriate behaviors during the shift. They did not recall who the other resident was present during the behavior. There should have been an incident report completed and was not sure why one was not completed. On 11/29/2024 at 10:49 AM, Licensed Practical Nurse #8 was not reached in a telephone interview. On 11/29/2024 at 12:51 PM, Registered Nurse #19 was not reached in a telephone interview. On 12/9/2024 at 12:23 PM, Licensed Practical Nurse #9 was not reached in a telephone interview. During a telephone interview on 12/10/2024 at 2:13 PM and on 12/11/2024 at 12:02 PM, Licensed Practical Nurse #4 (Assistant Director of Nursing) stated incident reports were completed at the time of the incident and provider and family notified immediately. If contact was made between two residents, a registered nurse assessment was needed. If residents were exposed to another resident's sexually inappropriate behavior, then a social worker typically followed up. On 1/9/2024, they could not recall why there was no assessment completed for Resident #2 and there should have been an assessment completed. They stated they started the incident report the day after the incident (1/10/2024) because one was not started on 1/9/ 2024. Staff was trained to start incident reports and they were not sure why one was not started on 1/9/ 2024. The provider and family were not notified timely for Resident #1 and # 2. Licensed Practical Nurse #16 should have updated the care plan per their nursing note for keeping the resident seated at a table with residents of the same sex and they were not aware the care plan was not updated. On 10/12/2024, they were updated while at home by Registered Nurse Supervisor #7 that Resident #1 kissed another resident and they did not recall who the other resident was. They completed the incident report on 11/7/2024 after it was found nobody initiated the paperwork. They believed the incident was investigated timely however the incident paperwork was not. New interventions were put in place on 10/12/2024 at the time of the incident for 15-minute checks. During a telephone interview on 12/11/2024 at 6:59 AM, the facility's Corporate Director of Nursing stated incident reports could be started by all nurses and were necessary so incidents could be investigated to rule out abuse and neglect. However, not all nurses completed incident reports and when the incident was reported to the Director of Nursing, the Director of Nursing was responsible to ensure the incident report was started if one had not. Incident reports should be initiated as soon as possible, and family and providers notified as soon as possible. All incidents required a registered nurse assessment including resident to resident sexual incidents and kissing. If a resident exposed themself in front of others and was masturbating, they expected the other resident would be assessed to ensure they were not touched. The other resident should also be interviewed to determine if they were emotionally alright, and it should be documented. Any staff could observe a resident for signs and symptoms of distress however the registered nurse assessed, and social work followed up. If no registered nurse was in the building at the time of an incident, the Director of Nursing or registered nurse on-call would come into the facility for assessment, or the registered nurse coming on duty the next shift assessed. The Interdisciplinary Team reviewed incidents to ensure current care planned interventions were effective and determined if they needed to change interventions. - On 5/20/2023, they expected an incident report to have been started immediately as well as an assessment by a registered nurse. 5/20/23 was a Monday, Registered Nurse #10 was the covering Director of Nursing (current Director of Nursing was on leave) and was staying locally. They believed Registered Nurse #10 would have come to the facility for assessment and was not sure why the assessment was not documented that day. They were not sure why the incident was documented late. - On 1/9/2024, they expected an assessment by a registered nurse and notifications were not timely. - On 1/22/2024, they expected an assessment by a registered nurse and notifications should have happened at the time of the incident. - On 10/12/2024, the former Director of Nursing was responsible to ensure the incident report was started. When the Administrator noted the incident report was not started on 11/7/2024, they directed Licensed Practical Nurse #4 (Assistant Director of Nursing) to initiate it. - For the incidents where other residents were exposed to the resident's genitalia or to acts of masturbation, there should have been documentation who the other resident(s) were and whether the other resident(s) had any negative effects from the behavior. 10NYCRR 415. 4(b)(3)t as it was not in their scope. They expected a registered nurse to assess. On 10/20/2023, they did not recall who the other residents were in the dining room and did not recall if the other residents were assessed. If there was a supervisor on shift, they would have notified them for an assessment. They did not recall who the supervisor was. They stated the resident was mean and the facility just allowed the behavior. During a telephone interview on 11/29/2024 at 10:23 AM, Licensed Practical Nurse #1 stated when there was an incident, the registered nurse took care of care plan changes. If someone was exposed to a resident's inappropriate sexual behavior, they would monitor the other resident, talk with them to ensure they were alright and note any concerns. When there were instances of resident sexually inappropriate behaviors, the registered nurse should be notified for an assessment. On 1/24/2024, they did not recall who Resident #1 exposed themself to and did not recall if a registered nurse assessed the other resident. Resident #1 continued to have current sexually inappropriate behaviors and 15-minute checks were not effective in preventing recurrence of behaviors. Licensed Practical Nurses #8 and #9 and Registered Nurse #19 were not able to be reached for interviews. During a telephone interview on 12/10/2024 at 2:13 PM and on 12/11/2024 at 12:02 PM, Licensed Practical Nurse #4 (Assistant Director of Nursing) stated incident reports were completed at the time of the incident and the provider and family were notified immediately. If contact was made between two residents a registered nurse assessment was needed. If residents were exposed to another resident's sexually inappropriate behavior, then a social worker typically followed up. On 1/9/2024, they could not recall why there was no assessment completed for Resident #2 and there should have been an assessment completed. They stated they started the incident report the day after the incident (1/10/2024) because one was not started on 1/9/ 2024. Staff were trained to start incident reports and they were not sure why one was not started on 1/9/ 2024. The provider and family were not notified timely for Residents #1 and # 2. Licensed Practical Nurse #16 should have updated the care plan per their nursing note for keeping the resident seated at a table with residents of the same sex and they were not aware the care plan was not updated. On 10/12/2024, they were updated while at home by Registered Nurse Supervisor #7 that Resident #1 kissed another resident and they did not recall who the other resident was. They completed the incident report on 11/7/2024 after it was found nobody completed the paperwork. They believed the incident was investigated timely and just the incident paperwork was not. New interventions were put in place on 10/12/2024 at the time of the incident for 15-minute checks. During a telephone interview on 12/11/2024 at 6:59 AM, the facility's Corporate Director of Nursing stated incident reports could be started by all nurses and were necessary so incidents could be investigated to rule out abuse and neglect. However, not all nurses completed incident reports and when the incident was reported to the Director of Nursing, the Director of Nursing was responsible to ensure the incident report was started if one had not been. Incident reports should be initiated as soon as possible, and family and providers notified as soon as possible. All incidents required a registered nurse assessment including resident to resident sexual incidents and kissing. If a resident exposed themself in front of others and was masturbating, they expected the other resident would be assessed to ensure they were not touched. The other resident should also be interviewed to determine if they were emotionally alright, and it should be documented. Any staff could observe a resident for signs and symptoms of distress however the registered nurse assessed, and social work followed up. If no registered nurse was in the building at the time of an incident, the Director of Nursing or registered nurse on-call would come into the facility for assessment, or the registered nurse coming on duty the next shift assessed. The Interdisciplinary Team reviewed incidents to ensure current care planned interventions were effective and determined if they needed to change interventions. The Corporate Director of Nursing stated the following about incidents involving Resident #1: - on 5/20/2023, they expected an incident report to have been started immediately as well as an assessment by a registered nurse. Registered Nurse #10 was the covering Director of Nursing and was not sure why the assessment was not documented that day. They were not sure why the incident was documented late. - On 1/9/2024, they expected an assessment by a registered nurse and notifications were not timely. - On 1/22/2024, they expected an assessment by a registered nurse and notifications should have happened at the time of the incident. - On 10/12/2024, the former Director of Nursing was responsible to ensure the incident report was initiated. When the Administrator noted there was no incident report, they directed Licensed Practical Nurse #4 (Assistant Director of Nursing) to initiate it on 11/7/ 2024. - For the incidents where other residents were exposed to Resident #1's genitalia or to acts of masturbation, there should have been documentation who the other resident(s) were and whether the other resident(s) had any negative effects from the behavior. 10 NYCRR 415. 4(b)(1)(i) | Plan of Correction: ApprovedDecember 31, 2024 F 600 483. 12 Abuse and Neglect 1. Immediate Corrective Action: ??? Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. ??? Resident #2 was discharged from Valley View Manor on 3/26/ 24. ??? Resident #5 had an RN assessment and was interviewed by the Director of Nursing on 12/20/24 and stated she is not terrified and is no longer uncomfortable around resident # 1. Resident #5 stated that I just ignore him or move away if I find myself too close to him. Resident #1 has not engaged with me since our encounter previously.??ΓΏ ??? Resident #1 had his care plans reviewed on 12/20/ 24. No revisions are currently needed. Interventions will include, 1:1 monitoring following any incidents, ongoing medical review to focus on medication management to address any underlying conditions contributing to behavioral issues. Will continue with routine psychiatric evaluations and adjust treatment plans as needed. ??? Resident #1 refused to be seen by the psychiatrist on 12/5/24, was sleeping when the psychiatrist attempted to see him on 12/19/24 and is scheduled to be seen 1/2/ 24. ??? There are no updates regarding resident #1 transfer to an all-male unit or another facility, However the facility actively investigating all available options. ??? LPN #4, LPN #8, LPN #1 and RN #7 will be educated on the Abuse prevention and Reporting Policy and procedures by 12/27/ 24. ??? LPN #16, LPN #14, LPN #9, RN #19, LPN #15 and RN #20 are no longer employed at Valley View Manor. 2. Identification of Others: The facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. ??? The Director of Nursing conducted interviews with all cognitive residents residing on resident #1 unit on 12/20/24 regarding the care and services they receive. There were no other allegations of abuse, neglect, misappropriation and exploitation made at the time of these interviews. During the interviews all residents denied being fearful or expressed psychological effects as a result of resident #1 or any other resident. 3. Measures/ Systemic Changes: The facility will conduct the following to prevent this practice from occurring in future: ??? Abuse Prevention and Reporting Policy was reviewed with revisions to include: Investigation: o victim and aggressor assessment, o obtaining statements from involved residents and witnessing residents, o Resident statements will be attempted despite cognitive status o All involved and witnessing residents will be monitored to determine psychological effects or change in behavior by social services or designee. The following information must be available for the investigators upon request: ??? All statements obtained ??? The Administrator/Director of Nursing will be notified immediately of any allegation of Abuse. An investigation will be initiated, the Victim and Aggressor will have a timely assessment completed, Accident and Incident initiated with staff statements, resident(s) statements, and any other potential witnesses. Emergency contact and medical provider notified timely and immediate care plan interventions initiated. Involved and witnessing residents will be interviewed and followed up for any potential psychological effects or change in behavior. Pending the outcome of the investigation, timely notification to state and local agencies will be completed. All staff that provide care to the involved residents will be notified of the interventions. ??? Education and in-servicing will be provided to all employees on the Abuse Prevention and Reporting Policy and revisions with emphasis on the importance of reporting immediately to the Administration team to ensure a full and timely investigation is completed and the procedures found in the policy are followed. Education and in-servicing will be completed upon new hire, annually and as needed by the Director of Nursing/Designee. 4. Quality Assurance Monitoring: The Administrator/Designee will investigate all reports of Abuse and Neglect to ensure a full investigation is completed and the Abuse Prevention and Reporting policy and procedures are followed. All accident and incident reports will be reviewed in the morning report to ensure that Accident and Incident reports are completed accurately, timely, and thorough. Accident and Incident reports will be audited weekly to ensure that all reports are completed timely, nursing assessments, witness statements obtained and notifications of family and medical have been completed. Any issues identified from these audits will be corrected immediately, and the information obtained from the audits will be reviewed at the Quality Assurance meeting. 5. Responsible Party and Expected Date of Completion: The Administrator/ Designee is responsible for correcting this deficient practice and completion date (MONTH) 26, 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 11, 2024
Corrected date: January 26, 2025
Citation Details None | Plan of Correction: ApprovedDecember 31, 2024 F 610 483. 12 Abuse and Neglect 1. Immediate Corrective Action: ??? Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. ??? Resident #2 was discharged from Valley View Manor on 3/26/ 24. ??? Resident #5 had an RN assessment and was interviewed by the Director of Nursing on 12/20/24 and stated she is not terrified and is no longer uncomfortable around resident # 1. ??? Resident #1 had his care plans reviewed on 12/20/ 24. No revisions are currently needed. ??? LPN #4, LPN #8, LPN #1 and RN #7 will be educated on the Abuse prevention and Reporting Policy and procedures by 12/27/ 24. ??? LPN #16, LPN #14, LPN #9, RN #19, LPN #15 and RN #20 are no longer employed at Valley View Manor. 2. Identification of Others: The facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. ??? The Director of Nursing conducted interviews with all cognitive residents residing on resident #1 unit on 12/20/24 regarding the care and services they receive. There were no other allegations of abuse, neglect, misappropriation and exploitation made at the time of these interviews. During the interviews all residents denied being fearful or expressed psychological effects as a result of resident #1 or any other resident. 3. Measures/ Systemic Changes: The facility will conduct the following to prevent this practice from occurring in future: ??? Abuse Prevention and Reporting Policy was reviewed with revisions to include: Investigation: o victim and aggressor assessment, o obtaining statements from involved residents and witnessing residents, o Resident statements will be attempted despite cognitive status o All involved and witnessing residents will be monitored to determine psychological effects or change in behavior by social services or designee. The following information must be available for the investigators upon request: ??? All statements obtained ??? The Administrator/Director of Nursing will be notified immediately of any allegation of Abuse. An investigation will be initiated, the Victim and Aggressor will have a timely assessment completed, Accident and Incident initiated with staff statements, resident(s) statements, and any other potential witnesses. Emergency contact and medical provider notified timely and immediate care plan interventions initiated. Involved and witnessing residents will be interviewed and followed up for any potential psychological effects or change in behavior. Pending the outcome of the investigation, timely notification to state and local agencies will be completed. All staff that provide care to the involved residents will be notified of the interventions. ??? Education and in-servicing will be provided to all employees on the Abuse Prevention and Reporting Policy and revisions with emphasis on the importance of reporting immediately to the Administration team to ensure a full and timely investigation is completed and the procedures found in the policy are followed. Education and in-servicing will be completed upon new hire, annually and as needed by the Director of Nursing/Designee. 4. Quality Assurance Monitoring: The Administrator/Designee will investigate all reports of Abuse and Neglect to ensure a full investigation is completed and the Abuse Prevention and Reporting policy and procedures are followed. All accident and incident reports will be reviewed in the morning report to ensure that Accident and Incident reports are completed accurately, timely, and thorough. Accident and Incident reports will be audited weekly to ensure that all reports are completed timely, nursing assessments, witness statements obtained and notifications of family and medical have been completed. Any issues identified from these audits will be corrected immediately, and the information obtained from the audits will be reviewed at the Quality Assurance meeting. 5. Responsible Party and Expected Date of Completion: The Administrator/ Designee is responsible for correcting this deficient practice and completion date (MONTH) 26, 2025. |