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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 11, 2024
Corrected date: N/A
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 residents were free from abuse and failed to protect residents from further abuse for 2 of 2 residents (Resident #2 and 4) reviewed, and 6 unidentified residents. Specifically, Resident #1 was cognitively impaired with a history of sexually inappropriate behaviors and there were no documented interventions to address the resident's ongoing behaviors or to protect other residents from abuse. Resident #2, a cognitively impaired resident, was touched on their breast by Resident #1. Two weeks later, Resident #2 was documented as being touched inappropriately by Resident #1. 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 effective to prevent recurrence. Resident #4, a cognitively impaired resident had their back and buttocks rubbed by Resident #1. Subsequently, Resident #1 kissed unidentified residents on two occasions, and continued to expose themselves and masturbate in front 6 unidentified residents on multiple occasions and the unidentified residents were not documented as assessed to determine if they had a negative outcome. 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. The facility policy, Resident Supervision 15 Minute/Frequent Checks, revised 3/2021, documented 15 Minute or Frequent Checks was a resident being monitored by a facility staff member to ensure the resident or other residents were safe. Prior to considering a resident for 15 Minute/Frequent Checks, an assessment and plan was to be completed by the Interdisciplinary Team to assess need. Interventions should be developed to recognize, evaluate, and analyze specific behaviors to help identify interventions; identify and develop behavior plans; and address, eliminate or reduce underlying causes of distressed behavior. Medical evaluation was required for any resident determined to be in need of intensive supervision. The Comprehensive Care Plan and certified nurse aide plan would be updated and reviewed at least weekly for appropriateness of 15 Minute/Frequent Checks and possible care plan changes. The certified nurse aide was to document all resident activity, behaviors, etc. This would be completed each shift. Resident #2 had [DIAGNOSES REDACTED]. The 12/15/2023 Minimum Data Set assessment documented the resident's cognition was severely impaired. Resident #4 had [DIAGNOSES REDACTED]. Resident #1: 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, and required supervision for walking in their room and corridor. Resident #1's Comprehensive Care Plan initiated 4/27/2023 documented the resident demonstrated episodes of inappropriate reaching and touching of others, inappropriate comments with sexual overtones, and exposing body parts. Interventions included: 2 staff members for all care; provide support to the resident; and psych evaluation as needed. The resident had the potential to abuse others. Interventions included monitor mood and behavior and provide early interventions; room change or unit change if possible; set limits, and counsel on inappropriate behaviors; if behavior symptoms were unmanageable, call 911 and send the resident to the emergency room for further evaluation. The 4/24/2023 Physician #18 progress note documented the resident was deemed incompetent to make decisions and guardianship was in place. The resident had dementia from a [MEDICAL CONDITION] and currently had no behaviors. The 5/13/2023 at 12:10 AM note Licensed Practical Nurse #9 progress note documented the resident was reported to have made inappropriate comments towards a unit assistant and stated they should get naked together. The resident was reminded to be appropriate, and staff would continue reminding the resident to not make comments. 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 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. There was no documented evidence Resident #1's care plan was updated timely and no documented evidence Resident #4 was assessed timely. A 5/23/2023 at 11:16 AM Social Worker #5 progress note documented they spoke with Resident #1 regarding the incident with Resident #4. Resident #1 could not recall the incident. The resident was educated on keeping their hands to themself, as that type of behavior could get them in trouble. The resident was asked to repeat what Social Worker #5 said and if they understood. The resident said they understood. The updated 5/23/2023 comprehensive care plan completed by Registered Nurse #10 documented the resident had altered health maintenance and was an abuser/aggressor. Goals included the resident would stop abusive behavior immediately after staff intervened x 90 days. Interventions included 15-minute checks, cause of the abuse would be ascertained and addressed, residents would be immediately separated, further abusive behaviors would be observed, and the rights of others would be reviewed as needed. The 8/13/2023 at 9:30 PM Registered Nurse #19 progress note documented the resident remained on 30-minute checks throughout the shift. There were no issues noted until 9:30 PM when the resident was found with their pants down in the dining room demonstrating inappropriate sexual behavior while another resident was present at a distant table. The resident was encouraged to return to their room and would continue 30-minute checks. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence. The 10/30/2023 at 9:29 PM Licensed Practical Nurse #15 progress note documented Resident #1 was in dining room with others present (unidentified). The resident's pants were pulled down to their thighs, exposing themself and they were rubbing their genitals. The resident was educated that the behavior was not acceptable. There was no documented evidence the facility investigated the incident to identify the other residents present at the time and if the other residents were impacted by Resident #1's behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence of inappropriate sexual behaviors in the dining room. The 10/31/2023 at 10:08 AM Social Worker #5 progress note documented Resident #1 was spoken to about their behavior in the dining room. They were educated that the behavior was not acceptable, and they would not be able to go to the dining room if the behavior continued. The 1/9/2024 at 10:11 PM Licensed Practical Nurse #16 progress note documented an aide reported the resident was touching another resident's breast (Resident #2) outside of their clothing during breakfast and they were immediately separated. Resident #2 did not appear aware of incident. Resident #1 was educated about inappropriate behavior and kept on the other side of the dining room. They discussed with staff to keep the resident at a table to include the same sex, moving forward. The 1/9/2024 Incident Report completed by Licensed Practical Nurse #4 (also the Assistant Director of Nursing) documented at 9:44 PM, the resident 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 1/10/24 at 2:10 PM. There was no documented evidence the residents were assessed timely. The Comprehensive Care plan, updated 1/11/2024 documented Resident #1 was to have immediate redirection to private areas during acts/times of sexual behavior, provide redirection as needed away from peers of opposite sex, follow with psychiatry, and medications were to be reviewed. There was no documented evidence the care plan was updated with interventions to keep the resident at the dining room table with the same sex and no documented interventions to protect Resident #2 from further abuse. The 1/22/2024 at 6:05 PM Licensed Practical Nurse #14 progress note documented the resident was seen rubbing their genitalia on Resident #2. As soon as Resident #1 noticed they were seen, they stopped and headed out of the dining room. The 1/22/2024 at 8:30 PM Licensed Practical Nurse #8 progress note documented the nurse reported earlier in the shift, Resident #2 was touching Resident #1's private areas. 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, and Resident #1 was placed on 15-minute checks. The incident was reported to the Department of Health and the physician and resident representative were notified on 1/24/2024. There was no documented evidence the residents were assessed timely. The Comprehensive Care Plan, updated 1/22/2024 documented new interventions included to approach Resident #1 in a calm consistent manner, for refusals of care, reapproach at another time, monitor changes in mood/behavior and report to provider, provide resident with opportunity to express feelings through 1:1 and group visits, use the resident's name and explain the purpose upon approach, Resident #1's 1/23/2024 updated Comprehensive Care Plan documented 15-minute checks. 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 (unidentified). They told the resident to pull their pants up and they then walked to their room. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence Resident #1's care plan was updated with interventions to prevent recurrence. 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 (unidentified) who was asleep at the next table. Resident #1 changed chairs to be closer to the sleeping resident, they pulled their pants down, exposed themself and was touching themself. They told the resident to pull their pants up and instructed aides to move the resident. Resident #1 continued 15-minute checks. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence. The 1/30/2024 at 11:12 PM Assistant Director of Nursing Licensed Practical Nurse #4 progress note documented the resident was seen by the nurse practitioner (unidentified) to review medications and recent sexual behaviors. There was a new order for [MEDICATION NAME] (antiepileptic medication used for behaviors) 125 milligrams twice daily. The 5/24/2024 Medical Director progress note documented nursing notes were reviewed with times of inappropriate sexual behavior documented. The resident's dementia was permanent and progressive. They documented to start [MEDICATION NAME] (gastrointestinal medication, sometimes used for hypersexuality) 200 milligrams twice daily for inappropriate sexual behaviors. The 5/30/2024 at 12:07 PM Licensed Practical Nurse #3 progress note documented the resident was being sexually inappropriate to staff and other residents. No contact was made. The resident was encouraged to keep their hands to themself and not to use language around the opposite sex. The 7/29/2024 at 3:02 PM former Director of Nursing #20 progress note documented the resident wheeled up to another resident of the opposite sex (unidentified) and kissed them on the mouth. Staff immediately intervened and separated the residents. A new order was obtained to increase [MEDICATION NAME] to 400 milligrams twice daily. They would have 15-minute checks daily for 3 days to assist with monitoring the Resident #1's whereabouts and interactions with others. There was no documented evidence of an incident report and no documented evidence the facility determined if the other resident was impacted by the incident. The 7/30/2024 at 7:57 AM Licensed Practical Nurse #23 progress note documented the resident was observed several times standing in the hallway exposing themself and was redirected. The 7/30/2023 at 1:02 PM Licensed Practical Nurse #3 progress note documented the resident continued to be verbally inappropriate asking staff and residents of the opposite sex for sexual favors and they continued 15-minute checks. The 7/30/2024 at 8:49 PM Social Worker #5 progress note documented they spoke with Resident #1 about the incident of kissing another resident (unidentified). The resident did not recall the incident. They were educated to keep their hands to themselves, so they did not get in trouble. Resident #1's 7/30/2024 updated Comprehensive Care Plan documented 15-minute checks for 3 days. The 8/19/2024 updated Comprehensive Care Plan documented interventions included upon completion of meals, Resident #1 would be escorted from the dining room and encouraged to sit in highly visible areas. The 8/26/2024 Nurse Practitioner #22 progress note documented the resident was seen because staff reported despite [MEDICATION NAME] 400 milligrams twice daily, the resident continued with sexual behaviors. The plan included to increase [MEDICATION NAME] to 600 milligrams twice daily. The 9/20/2024 at 12:02 PM Licensed Practical Nurse #3 progress note documented the resident verbalized wanting female residents and staff to perform sexual acts and saying they wanted to do sexual acts to them. No interventions stopped the behavior. The 9/21/2024 physician order [REDACTED]. 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 (unidentified) in the dining room and the residents were separated. The Director of Nursing and provider were notified. Resident #1 was placed on 15-minute checks. 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. The 10/12/2024 updated Comprehensive Care Plan documented Resident #1 had behavior symptoms. Interventions included 15-minute checks (discontinued on 10/24/2024). The updated 10/17/2024 Comprehensive Care Plan documented Resident #1 would be escorted in and out of the dining room for activities, meals, and supervised at all times while in the dining room area. The resident would be escorted out of the dining room immediately following completion of the meal/activity. The 10/24/2024 at 6:09 PM Registered Nurse #25 progress note documented the resident touched the arm of another resident (unidentified). Both residents assessed with [REDACTED]. Resident #1's care plan was updated and orders for 15-minute checks ordered. Placed in physician book for medication review. The 10/24/2024 at 6:11 PM Incident Report completed by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed grabbing another resident's arm (Resident #6). The provider and family were notified on 10/24/2024. The 10/24/2024 at 9:01 AM Social Worker #5 progress note documented they spoke to the resident who had no recollection of inappropriate behaviors the day before. They were re-educated on keeping hands off others. They also contacted the resident's guardian about inappropriate sexual behaviors and to inquire about alternate facilities that could accommodate the resident. The resident likely needed an all-male unit. The 10/24/2024 updated Comprehensive Care Plan documented Resident #1 had behavior symptoms. Interventions included 15-minute checks for 3 days, the resident would not be seated with any residents of the opposite sex during activities or meals. During an interview on 11/26/2024 at 12:03 PM, Resident #5 stated they resided on the resident's unit and the resident had behaviors that made them very uncomfortable, and they were terrified of them. Resident #1 had come to their room door (did not recall date), pulled their pants down exposing their genitals and told Resident #5 look at it. This past Saturday, they were wheeling by Resident #1's open door (bed closest to the doorway) and Resident #1 was naked and masturbating. They reported it to staff and staff closed the resident's door. In the dining room, they had seen the resident approach multiple residents of the opposite sex and try to touch them. They also witnessed the resident kiss another resident although that was a while ago. They stated it seemed like nothing was ever done to prevent the resident from behaving badly. During an interview on 11/26/2024 at 12:55 PM, Certified Nurse Aide #17 stated the resident had a history of [REDACTED]. When the resident displayed the behavior, they were to take them back to their room. The resident was supposed to always be within eyesight of staff. In the dining room in the past, the resident had tried to reach out and grab residents of the opposite sex. Now the resident was brought to the dining room after everyone else was seated and sat with residents of the same sex. They were aware of other instances where the resident was sexually inappropriate with other residents but did not recall the circumstances or what was done as a result. During a telephone interview on 11/29/2024 at 9:36 AM, Licensed Practical Nurse #15 stated residents involved in sexually inappropriate behaviors needed to be assessed. They could not assess residents to determine if there was negative impact 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: ?Çó Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. ?Çó Resident #2 was discharged from Valley View Manor on 3/26/24. ?Çó 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.?Ç¥ ?Çó 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. ?Çó 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. ?Çó There are no updates regarding resident #1 transfer to an all-male unit or another facility, However the facility actively investigating all available options. ?Çó 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. ?Çó 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. ?Çó 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: ?Çó 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: ?Çó All statements obtained ?Çó 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. ?Çó 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: N/A
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) | Plan of Correction: ApprovedDecember 31, 2024 F 610 483.12 Abuse and Neglect 1. Immediate Corrective Action: ?Çó Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. ?Çó Resident #2 was discharged from Valley View Manor on 3/26/24. ?Çó 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. ?Çó Resident #1 had his care plans reviewed on 12/20/24. No revisions are currently needed. ?Çó 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. ?Çó 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. ?Çó 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: ?Çó 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: ?Çó All statements obtained ?Çó 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. ?Çó 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. |