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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 So | 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.?Ø 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: 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 | 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. |