The Plaza Rehab and Nursing Center
November 1, 2018 Complaint Survey

Standard Health Citations

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

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 1, 2018
Corrected date: November 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews conducted during an abbreviated survey (NY 398), the facility did not have evidence that all alleged violations involving resident abuse by facility staff are reported to New York State Department of Health (NYS DOH) and local law enforcement. This was evidenced in 1 out of 4 sampled incidents (Resident #1). Specifically, Resident # 1's family reported that he was concerned that the resident had been raped in the facility. The facility did not report this allegation to NYS DOH or local law enforcement. Th findings include: The facility Policy and Procedure on Abuse with review date of 04/23/2018 states, It is the policy of The Plaza Rehab and Nursing Center that abuse allegations are reported per Federal and State Law. Local law enforcement will be notified of any reasonable suspicion of crime against a resident in the facility. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 08/10/2018 documented that Resident #1's cognitive skills for daily decision making was severely impaired. The Facility Occurrence Report dated 08/27/2018 documented that Resident#1's family member reported to the Administration that he had concerns that Resident #1 was raped in the facility. A friend visited with the resident and reported to him that the resident stated rape to a staff. The facility investigation included staff statements and assessment of the resident. The Administrative Determination section of the report documented there is no cause to believe any alleged resident abuse, exploitation, or neglect regarding the resident has occurred. It was also documented that the allegation was not reported to the Department of Health (DOH). The Administrator was interviewed on 10/19/2018 at 10:40 AM and stated that the allegation was not reported to the State because the facility was not able to substantiate the abuse. Based on the incident manual, only substantiated allegations are reported. The allegation was not reported to the law enforcement. The Acting Director of Nursing Service was interviewed on 10/19/2018 at 2:00 PM and stated that the allegation was not reported to the DOH. If the facility determined that an abuse or neglect is substantiated or if the facility cannot rule out abuse, it will be reported to the State. 415.4(b)(I)(i)

Plan of Correction: ApprovedNovember 8, 2018

Resident # 1 was transferred to the hospital 10/30/2018 and has not returned to the facility. Local Law enforcement (New York Police Department 52nd Precinct) was notified and responded to the facility. The facility staff worked with the officer and provided required documentation and staff interview as indicated.

Residents and family members who allege abuse are at risk to be affected by this deficient practice. A review of all residents and or family who reported abuse in the last 3 months were reviewed. No further deficient practice was identified.
The Policy and Procedure regarding abuse allegations was reviewed and revised to ensure allegations of abuse are reported to the State Survey Agency and the appropriate local law enforcement agency timely.
Staff was in-serviced regarding the policy and procedure update.
Administrative staff was reeducated regarding the update to the State Operations Manuel.
In-service was conducted with all off shift supervisors to notify Administrative staff of all abuse allegations immediately.
The Director of Nursing will review all accident and incident reports to identify potential alleged violations including abuse neglect, exploitation or mistreatment, including injuries of unknown source weekly. Potentially identified issues will be referred to the administrator immediately.
All finding will be reported to the Quality Improvement committee monthly. The Director of Nursing will be responsible for monitoring compliance.