Huntington Hills Center for Health and Rehabilitation
February 14, 2019 Complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Actual harm has occurred
Citation date: February 14, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review during an abbreviated survey (Complaint # NY 681) the facility did not ensure the residents' rights to be free from neglect for one (Resident #1) of three residents reviewed for Resident Neglect. Specifically, a Certified Nursing Assistant (CNA #1) and a Licensed Practical Nurse (LPN #1) transferred the resident from the floor to bed without reporting to, or ensuring that the resident was assessed by, a Registered Nurse (RN), Nurse Practitioner (NP) or a physician (MD) after an unwitnessed fall. Thereafter, the resident was in pain and was unable to bear weight to the right leg. A physician or NP was not notified for 7 hours after a change in the resident's condition was identified by the facility staff. Additionally, the resident was not assessed by a qualified clinician for at least 23 hours after the fall. Subsequently, the resident was transferred to the hospital with a [DIAGNOSES REDACTED]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings were: The facility policy titled Resident Abuse dated 12/2016 defined Neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility policy titled Accident-Reportable Event Protocol dated 11/2018 documented it is the responsibility of all staff to report all incidents and accidents that occur at the facility, staff will notify the Nursing Supervisor immediately when an incident occurs. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required extensive assistance of two persons with bed mobility and extensive assistance of one person for transfer and ambulation. The Comprehensive Care Plan (CCP) titled at Risk for Falls dated 01/18/2018 documented Resident #1 was at risk for falls. Interventions included; anticipate and meet the resident's needs, encourage the resident to participate in activities, Physical Therapy (PT) evaluate and treat as ordered or as needed. 02/08/2018 ensure the resident is wearing shoes when ambulating and nonskid socks only when in bed. 02/13/2018 alarmed floor mats over graduated floor mats, bilateral graduated floor mats, hip savers at all times and the resident to be first on the assignment to be provided with morning care. The resident had documented actual falls on, 02/07/2018 (no injuries), 02/13/2018 found on the floor next to the bed (no injury) and 02/20/2018 hospital transfer/right [MEDICAL CONDITION]. The medical record lacked documented evidence of an incident/accident, fall or complaints of pain from 2/14/18 - 2/19/18. The Nursing Progress Note (NPN) (authored by LPN #2) dated 02/19/2018 10:46 PM documented Resident #1 was unable to bear weight on her right leg. She denied pain or discomfort for the majority of the shift. While in bed the resident complained of pain to the right leg. [MEDICAL CONDITION] noted to the lower portion (right leg). A telephone order was obtained from the MD to get an X-ray of the right hip. X-ray Company would send a technician in the morning. The Radiology Results Report (X-ray of right hip with pelvis) dated 02/20/2018 9:02 AM documented an Intertrochanteric Right Femur Fracture. An Accident Report dated 02/20/2018 documented at 8:00 AM Resident #1 was observed with swelling and bruising to her right hip/thigh. Her right leg was shorter than the left and externally rotated. The resident had pain. The physician was notified and examined the resident on 02/20/2018 at 9:00 AM. The Medical Progress Note (MPN) dated 02/20/2018 at 9:47 AM documented; evaluated another recent fall. X-ray was done this morning, right [MEDICAL CONDITION]. Will need to transfer to the hospital for an orthopedic evaluation. The personnel file for CNA #1 included a Counseling Report dated 2/22/2018 that documented CNA #1 failed to report a fall. The CNA and Nurse transferred the resident from the floor to the bed, the supervisor was not notified. CNA #1 was suspended for two days. CNA #1's in-service record revealed an in-service dated 06/06/2017 including; Safety and Accident Prevention, Resident Abuse/Neglect/Mistreatment/Rules and Reporting. 11/17/2017 Resident Safety/Fall Prevention, 10/31/2017 reporting Accidents/Incidents The personnel file for LPN #1 included a Counseling Report dated 2/22/2018 that documented LPN #1 failed to report a fall. LPN #1 and CNA #1 assisted Resident #1 back to bed, the supervisor was never notified. She was suspended for two days. LPN #'1s in-service record revealed an in-service dated 06/08/2017 Resident Abuse/Neglect/Mistreatment and Rules and reporting, 11/30/2016 Resident Safety/Fall Prevention. The hospital discharge record dated 02/23/2018 documented patient required surgery for [REDACTED]. The Risk Manager Review (Summary of Investigation) dated 02/23/2018 documented the investigation revealed that there was no reasonable cause to believe any alleged resident abuse, mistreatment or neglect regarding this resident had occurred. The 6:30 AM - 2:30 PM LPN #1 (charge nurse) was interviewed on 01/07/2019 at 11:17 AM and stated she responded to a report of a fall at approximately 9:00 AM on 02/19/2018. Resident #1 was on the floor mat, and CNA #1 was present in the room. She asked the resident to move her legs and arms, and the resident denied pain. She asked CNA #1 to help get the resident up off the floor. CNA #1 and herself, both picked Resident #1 up off the floor. She did not notify anyone including the Registered Nurse Supervisor (RNS) or the on-coming shift. She did not fill out an incident/accident report. The 6:30 AM - 2:30 PM CNA #1 was interviewed on 01/07/2019 at 12:22 PM she and stated, in the morning she walked into Resident #1's room and found her sitting on the floor mat. She immediately called the nurse in charge (LPN #1), she came and asked the resident if she was ok. LPN #1 asked the resident to move her feet, legs and hands. Both CNA #1 and LPN #1 picked the resident up off the floor and placed her in bed. CNA #1 stated that the resident was not in pain. LPN#1 instructed her to lift the resident from the floor. CNA #1 stated that she lied and told the Assistant Director of Nursing Services (ADNS) that Resident #1 did not fall. The Nurse Practitioner was interviewed on 01/07/2019 at 2:02 PM, and stated, on 02/20/2018, she evaluated Resident #1. The right leg was noted to be shorter than the left and was externally rotated which indicated a pathological event. The resident was transferred to the hospital. The NP stated that she expected facility staff to notify her or the physician if a resident was found on the floor. The 3:00 PM - 11:00 PM LPN #2 was interviewed on 01/29/2019 at 1:30 PM and stated she was assigned to Resident #1 on 2/19/18. She did not get a report of an incident/accident or fall regarding Resident #1. LPN #2 stated at approximately 2:55 PM, CNA #3 reported to her that Resident #1 was not able to stand. The resident was sitting in her wheel chair when LPN #2 assessed the resident. The resident was able to stand up and there was no shortening of the leg. CNA #3 kept telling her something was wrong with the way the resident was standing. LPN #2 didn't think anything was wrong, therefore she did not call the RNS. At approximately 6:00-6:15 PM Resident #1 was toileted. Normally she required one person's assistance, however, two CNA's assisted her to the toilet. CNA #3 continued to tell her (LPN #2) that something was wrong with the resident. Toward the end of her shift Resident #1 was screaming for help. Resident #1 reported she was in pain. The resident had right leg pain and [MEDICAL CONDITION]. LPN #2 then called the MD and got an order for [REDACTED]. The LPN stated that she did not have an issue with the X-ray company coming to the facility in the morning because there was no indication that the resident had a fracture. If she would have noted that the resident had a fracture and she couldn't get an X-ray right away she would have sent the resident out to the hospital. LPN #2 stated that she did not notify the RNS. The nurses do the assessing of the residents including the LPN charge nurse. The RNS was made aware at the end of the shift. LPN #2's written statement provided to the facility dated 02/20/2018 documented at 2:55 PM (02/19/2018) a CNA informed her that Resident #1 was unable to stand. At 6:00 PM the resident was toileted and able to stand with assistance. At 10:25 PM the resident was in pain and unable to move her right leg. The ADNS was interviewed on 01/07/2019 at 2:57 PM, and stated she completed the ingestion investigation regarding Resident #1's fall. Initially CNA #1 and LPN #1 denied the incident. Later LPN #1 admitted that she knew the resident fell and she did not report the incident. The 2:30 PM - 10:30 PM CNA #3 was interviewed on 01/07/2019 at 3:15 PM and stated she was assigned to Resident #1 on 2/19/2018. Normally the resident required the assistance of one person for toileting. That evening the resident could not stand up, and she could not ambulate and her foot was bending under. She reported this to LPN #2 (charge nurse). LPN #2 checked her leg and then went away. After dinner the resident was toileted again and required two-person assistance. She called LPN #2 again to observe. The resident could bear weight on her leg. However, CNA #1 noted a change in the resident's transfer that was different from how she (the resident) normally transferred. The resident was uneasy during the transfer. Later that night the resident was placed in bed and CNA #5 assisted her, and they both reported to LPN #2 that the resident could not stand, and something was wrong with her leg. The 2:30 PM - 10:30 PM CNA #4 and CNA #5 were interviewed on 1/29/2019 separately via telephone. Both CNAs stated that they assisted CNA #3 in toileting Resident #1. The resident was in pain, she was frowning and grimacing. CNA #4 and CNA #5 reported the pain to LPN #2. The 7:00 AM - 3:00 PM RNS #1 was interviewed via telephone on 01/29/2019 at 11:29 AM she stated she was not made aware of any incident/accident regarding Resident #1. The MD was interviewed on 01/30/2019 at 11:33 AM, and stated he was called and ordered an x-ray for the resident however, could not recall the details of the call. He stated if a nurse called him and reported the patient could not ambulate and if there was pain he would tell them to get an X-ray, give pain medication and monitor. If the patient stable with pain medication we order the X-ray and its ok to wait until morning. He would expect the nurse to notify the supervisor. F600 (G) 415.15

Plan of Correction: ApprovedMarch 6, 2019

F 600
Resident #1
I.The resident was immediately assessed by NP on 2/20/2018 and was transferred to hospital for further follow up.
The LPN and the CNA assigned to resident on 2/19/2018 on the day shift who did not report the Accident/Incident to the RN/MD were immediately identified on 2/20/2018,educated on Accident/Incident Reporting on 2/22/2018 and again on 2/26/2018 and were suspended for 2 days for not following the protocol. Upon return both the LPN and the CNA were placed on monitoring via daily reporting and monitoring form.

The Risk Manager was immediately in-serviced by the DNS regarding the Abuse Reporting Protocol including root cause analysis in order to rule out Abuse, Neglect and Mistreatment on 3/5/19

All A/I from (MONTH) (YEAR) to Current period were reviewed by DNS to ensure the Abuse/neglect protocol was followed. No corrective action is required at this time.
All RNs, LPNs, CNAs were in-serviced by ADNS on Accident/Incident reporting and Abuse protocol on 2/22/2018.
II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice.
The DNS/ADNS will audit all LPNs via questionnaire form to ensure that the LPNs are aware/understand the importance of notifying the RN immediately for an RN assessment ,if an Accident/Incident occurs and for a Change in Condition.

The ADNS will provide education to all RNs, LPNs and CNAs regarding Abuse prevention protocol including A/Is .This education will continue to be provided until all staff receive this required education.
III. The following system changes will be implemented to ensure continuing compliance with regulations.

The Administrator, Medical Director and the Director of nursing reviewed the policy and Procedure on Abuse protocol related to A/Is with no revision necessary at this time.
All RNs,LPNs and CNAs will have education completed by the ADNS on Abuse prevention protocol/Accident Reporting during orientation, annually and on an as needed basis.
The DNS/ADNS will monitor for compliance through 2 medical record review and morning report review daily. Additional education and corrective actions will be provided as needed.
IV. The facility's compliance will be monitored utilizing the following quality assurance system
An audit tool will be created to monitor staff compliance related to Accident Reporting/Abuse Protocol .
The Risk Manager/Designee will conduct a weekly audit on 2 residents related to A/Is to ensure compliance with Abuse Protocol for the next 4 weeks with all findings being reported to the Administrator and Director of Nursing.Following the 4 weeks of auditing and no issues being identified,the frequency of auditing will be reduced to 2 residents A/Is monthly for the next 3 months. Corrective actions,such as additional re-education of staff on Accident Reporting will be completed as needed.
The Director of Nursing will report the findings of Abuse Protocol related to A/I audits at the next QAPI Committee meeting for evaluation and follow-up discussion.Reporting will continue for the next 3 months with a determination made at the end of this period if auditing needs to continue quarterly.
Responsible Person : Director of Nurtsing

FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review during an abbreviated survey (Complaint # NY 681) the facility did not ensure a physician or a Nurse Practitioner (NP) was notified of a change in the resident's clinical status for one (Resident #1) of three residents reviewed for significant change in condition. Specifically, a Certified Nursing Assistant (CNA #1) and a Licensed Practical Nurse (LPN #1) transferred the resident from the floor to bed without reporting to, or ensuring that the resident was assessed by, a Registered Nurse (RN), Nurse Practitioner (NP) or a physician (MD) after an unwitnessed fall. Thereafter, the resident was in pain and was unable to bear weight to the right leg. A physician or NP was not notified for 7 hours after a change in the resident's condition was identified by the facility staff. The findings were: The facility policy titled Accident-Reportable Event Protocol dated 11/2018 documented it is the responsibility of all staff to report all incidents and accidents that occur at the facility, staff will notify the Nursing Supervisor immediately when an incident occurs. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required extensive assistance of two persons with bed mobility and extensive assistance of one person for transfer and ambulation. The Comprehensive Care Plan (CCP) titled at Risk for Falls dated 01/18/2018 documented Resident #1 was at risk for falls. Interventions included; anticipate and meet the resident's needs, encourage the resident to participate in activities, alarmed floor mats over graduated floor mats, bilateral graduated floor mats, hip savers at all times and the resident to be first on the assignment to be provided with morning care. The CCP was updated on 02/20/2018 to include hospital transfer for right [MEDICAL CONDITION]. The medical record lacked documented evidence of an incident/accident, fall or complaints of pain from 2/14/18 - 2/19/18. The Nursing Progress Note (NPN) (authored by LPN #2) dated 02/19/2018 10:46 PM documented Resident #1 was unable to bear weight on her right leg. She denied pain or discomfort for the majority of the shift. While in bed the resident complained of pain to the right leg. [MEDICAL CONDITION] noted to the lower portion (right leg). A telephone order was obtained from the MD to get an X-ray of the right hip. X-ray Company would send a technician in the morning. An Accident Report dated 02/20/2018 documented at 8:00 AM Resident #1 was observed with swelling and bruising to her right hip/thigh. Her right leg was shorter than the left and externally rotated. The resident had pain. The physician was notified and examined the resident on 02/20/2018 at 9:00 AM. The Radiology Results Report (X-ray of right hip with pelvis) dated 02/20/2018 9:02 AM documented an Intertrochanteric Right Femur Fracture. The hospital discharge record dated 02/23/2018 documented patient required surgery for [REDACTED]. The 6:30 AM - 2:30 PM LPN #1 (charge nurse) was interviewed on 01/07/2019 at 11:17 AM and stated she responded to a report of a fall at approximately 9:00 AM on 02/19/2018. Resident #1 was on the floor mat, and CNA #1 was present in the room. CNA #1 and herself, both picked Resident #1 up off the floor. She did not notify anyone including the physician, NP and the Registered Nurse Supervisor (RNS) or the on-coming shift. The Nurse Practitioner was interviewed on 01/07/2019 at 2:02 PM, and stated, on 02/20/2018, she evaluated Resident #1. The right leg was noted to be shorter than the left and was externally rotated which indicated a pathological event. The resident was transferred to the hospital. The NP denied being notified of the fall or change in the resident's condition. The NP expected facility staff to notify her or the physician if a resident was found on the floor. The 3:00 PM - 11:00 PM LPN #2 was interviewed on 01/29/2019 at 1:30 PM and stated she was assigned to Resident #1 on 2/19/18. She did not get a report of an incident/accident or fall regarding Resident #1. LPN #2 stated at approximately 2:55 PM, CNA #3 reported to her that Resident #1 was not able to stand. CNA #3 kept telling her something was wrong with the way the resident was standing. LPN #2 didn't think anything was wrong, therefore she did not call the RNS. At approximately 6:00-6:15 PM Resident #1 was toileted. Normally she required one person's assistance, however, two CNA's assisted her to the toilet. CNA #3 continued to tell her (LPN #2) that something was wrong with the resident. Toward the end of her shift Resident #1 was screaming for help. Resident #1 reported she was in pain. The resident had right leg pain and [MEDICAL CONDITION]. LPN #2 then called the MD and got an order for [REDACTED]. The 2:30 PM - 10:30 PM CNA #4 and CNA #5 were interviewed on 1/29/2019 separately via telephone. Both CNAs stated that they assisted CNA #3 in toileting Resident #1. The resident was in pain, she was frowning and grimacing. CNA #4 and CNA #5 reported the pain to LPN #2. The 7:00 AM - 3:00 PM RNS #1 was interviewed via telephone on 01/29/2019 at 11:29 AM she stated she was not made aware of any incident/accident regarding Resident #1. The MD was interviewed on 01/30/2019 at 11:33 AM and stated that when he was called he ordered an x-ray for the resident however, could not recall the details of the call. He would expect the nurse to notify the supervisor. 415.3 (e)(2)(ii)(b)

Plan of Correction: ApprovedMarch 6, 2019

F 580
Resident#1
I.MD was called by LPN on 2/19/18 on the evening shift 7 hours after a change in condition noted.XRay was ordered.Resident was immediately transferred to the hospital 2/20/18 for follow up as a result of positive Xray ,per MD/NP order. Resident was assessed by NP on 2/20/18 prior to transferring resident to hospital.
a.The CNA and the LPN who were assigned to the resident on 2/19/18 during the day shift who did not report the incident to the RN and MD were immediately identified, in-serviced on 2/22/2018 and again on 3/1/2018 on change in condition and notification to RN and MD,subsequently were suspended for 2 days. Upon return, both the LPN and the CNA were placed on daily monitoring via daily employee and reporting form.
b.The LPN who was assigned to the resident on 2/19/18 on evening shift,who did not report residents change in condition to RN was immediately identified and re in-serviced on 2/21/2019 on the Change in condition,RN and MD/Np notification for further follow up.
All A/Is for the last 3 months(from (MONTH) (YEAR) to current) were reviewed by DNS to ensure the facility protocol for change in condition related to Accidents and Incidents, RN notification and MD/NP notification was followed. No corrective action needed.

All RNs,LPNS,CNAs will be educated by the ADNS regarding Change in condition, RN and MD/NP notification.
II.The following corrective actions will be implemented to identify other residents who may be affected by the same practice.
The ADNS will identify all residents with a change in condition. and ADNS/DNS will review all residents with a change in condition via morning report and daily review of the medical record to ensure the changes are reported to RN and NP/MD and documented in medical record.
The IDC team will review and revise as needed the plan of care for all identified residents with change in condition .The RN will update ,as needed the CNA kardex and will provide education to the unit staff on any revision to the plan of care.

III.The following system changes will be implemented to assure continuing compliance with regulations.

The policy and Procedure on Change in Condition and RN/MD notification was reviewed by the Administrator, Medical Director and the Director of Nursing.No revision necessary at this time.
The ADNS will continue to provide education to all RNs, LPNs, CNAs regarding the facility protocol related to RN notification and MD/NP notification for change in condition. This education will continue to be provided until all nursing staff receive this required education.
The DNS/ADNS will monitor for compliance through random review of 2 medical records daily. Additional education and corrective actions will be provided as needed.
IV. The facility's compliance will be monitored utilizing the following quality assurance system.
An audit tool will be created to monitor staff compliance with the Change in Condition and RN,MD/NP notification protocol.
The Unit Coordinators and the Nursing Supervisors will conduct a weekly audit on 2 residents related to Change in codition on each shift to ensure compliance with Residents Change in Condition Protocol for the next 4 weeks with all findings being reported to the Administrator and Director of Nursing.The ADNS will immediately intervene and re educate the staff if protocol not followed.Following the 4 weeks of auditing of Change in Condition Reporting being performed and no issues being identified, the frequency of auditing will be reduced to 2 residents related to Change in Condition on each shift monthly for the next 3 months. Corrective actions,such as additional education on reporting of Change in Condition will be provided as needed.
The Director of Nursing will report the audit findings regarding the Change in Condition,RN and MD/NP notification , at the next QAPI Committee meeting for evaluation and follow up discussion. Reporting will continue for the next 3 months with a determination made at the end of this period if auditing needs to continue and at what frequency.
Responsible Person : Director of Nursing