Elderwood at Waverly
August 27, 2018 Complaint Survey

Standard Health Citations

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 25, 2018
Corrected date: September 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY 633), the facility did not ensure a thorough and complete investigation was conducted for 2 of 7 residents (Residents #1 and 2) reviewed for allegations of abuse, neglect, or mistreatment. Specifically, when Residents #1 and 2 were involved in a sexual incident, the facility did not conduct a thorough investigation by interviewing pertinent staff, reviewing the residents behavioral histories, and putting effective measures in place to prevent recurrence or to provide protection to other vulnerable residents. Findings include: 1) Resident #2 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired and behavioral symptoms included rejection of care 4 to 6 out of 7 days. The resident required extensive assistance for dressing, and limited assistance for bed mobility, transfers, walking, toilet use, and personal hygiene. Nursing progress notes in Resident #2's medical record documented: - on 11/22/2017 at 9:19 PM, the registered nurse (RN) #1 Manager wrote the resident continued to have increased periods of confusion which worsened as the evening progressed. Staff voiced concerns regarding the resident's inappropriate comments toward staff and other female residents. Staff stated the resident spoke in a sexual nature, directing his comments at females. The physician was aware of the behaviors and recommended staff to continue to monitor and notify the physician if behaviors worsened. - on 12/21/2017 at 10:20 PM RN #2 Supervisor noted Resident #1 had her hands in Resident #2's pants, both denied any skin touching. Resident #2 stated he did not ask for this to occur. - on 12/21/2017 at 11:01 PM, licensed practical nurse (LPN) #3 noted a certified nurse aide (CNA) found Resident #2 coercing another resident (Resident #3) to touch him. Resident #3 answered that she had no idea what he was talking about. The facility's investigation and incident report documented on 12/21/2017 at 7:00 PM, in the dining room, Resident #1 was standing next to Resident #2 with her hand inside the back of his pants. The residents were separated and put on 15 minute checks. As the staff were ambulating Resident #1 away, Resident #2 was observed wheeling toward Resident #3 and making inappropriate sexual comments, staff again intervened. The social worker followed up with Resident #2 on 12/22/2017 and the resident had no recollection of the incident. The investigation concluded there had been no previous incident with the two residents and neither resident had a prior incident of this nature. The comprehensive care plan (CCP) revised on 12/22/2017, documented the resident had a sexually inappropriate interaction with a female resident on 12/21/2017 and no new interventions were added to the behavioral care plan. In the nursing progress note on 12/24/17 at 11:13 PM, LPN #3 wrote the resident was shooed away from female residents on and off all shift. He was caught in another female's room, stopped by females in the hall, was upset when not allowed to be near them. On 12/26/2017, the facility reported the incident of 12/21/2017 to the Department of Health (DOH) and documented Resident #2 instigated the incident and was put on 15 minute checks. The facility's plan to prevent recurrence documented there was no previous incident with the 2 residents and neither resident had a prior incident of this nature. Medication changes were made for Resident #1 and 15 minute checks for each resident would continue. Resident #2's nursing progress notes documented: - On 12/27/17 at 9:15 PM, LPN #4 wrote the resident had negative behaviors throughout whole shift toward multiple female residents. He was touching Resident #3 on her shoulders during dinner, and tried multiple times to approach her even after she told him he was bothering her. He tried to go around the table during dinner to reach Resident #6, told her he loved her, and asked her if she wanted him to stay with her. He was caught putting Resident #7's hand on his lap. Later the resident was helped to bed multiple times and got up unassisted to his wheelchair and out in hall way. - On 12/28/17 at 1:57 PM, LPN #5 noted the resident continued on 15 minute checks and had to be redirected when attempting to touch other residents. - On 12/29/17 at 2:31 PM, the social worker documented there was care planning meeting. The resident had an increase in sexually inappropriate behaviors and staff continued to redirect as needed. The resident's wife expressed concerns in regards to the recent increase in sexually inappropriate behaviors and asked if we could get an overall work up on the resident to rule out anything clinically that might cause increased behavior. - On 1/2/18 at 11:29 AM, RN #1 spoke to the Director of Nursing (DON) regarding the resident's 15 minute checks and they agreed to discontinue the 15 minute checks. The staff would continue to monitor the resident for any issues or concerns. - On 1/18/18 at 4:30 PM, RN #6 Supervisor noted 2 activity aides saw the resident being groped by Resident #1. The residents were immediately separated and the resident stated he was fine. Resident #1 had her hand on Resident #2's private parts, over his pants. - On 1/18/18 at 10:39 PM, LPN #3 documented the resident was challenging the private space of people, crowding. He encouraged a female resident to touch him inappropriately and sat very close to all the female residents. The resident was shooed away from the females. - On 1/20/2018 at 10:06 AM, the resident was on 15 minute checks due to sexual advances made by another resident. - On 1/21/18 at 8:50 PM, LPN #4 wrote that during dinner, the resident stated he missed his chance when she bent down to pick up a straw. The resident's care card (care instructions) dated 1/23/2017, documented he was on 15 minute checks due to sexual advances made by another resident. When interviewed on 1/24/2018 at 9:30 AM, activity aide #7 stated on 1/18/2018 at approximately 4:45 PM, she saw Resident #1 and 2 sitting at a table together outside the dining room. Resident #2 was in his wheelchair and Resident #1 was in a stationary chair with her walker nearby. Resident #1 had her hand in Resident #2's crotch area and he was scooting closer and encouraging her. The other activity aide and CNA #8 were nearby and intervened. When interviewed on 1/24/2018 from 9:50 to 10:10 AM, CNA #8 stated on 12/21/2017, Resident #1 was in a chair facing the nursing station and Resident #2 was in his wheelchair facing the opposite direction with his front side in complete view of the CNA. She stated she saw Resident #1's hand down the front of Resident #2's brief. She stated she pulled him away and went to get the nurse. She stated Resident #2 then self propelled his wheelchair over to Resident #3 and made a sexually inappropriate comment to her. She stated she then took him away and did not leave him alone near female residents. She stated Resident #2 knew what he was doing and female residents were not safe around him. She stated on 1/18/2018, the resident had his back to her and she did not see the touching. When activity aide #7 said something, she pulled him away from Resident #1 and kept him with her while she told the nurse. She stated they had always been doing 15 minute checks on Resident #2 and it was difficult to keep track of him. She stated there were often only 3 CNAs on the unit and it was difficult to do the checks as he could move quickly on his own. She stated 15 minute checks did not keep him away from the other residents. When interviewed on 1/24/2018 at 1:45 PM, LPN #5 stated she was unaware of any incidents with residents other than Resident #1. When asked about her note on 12/28/2017, she stated she had to redirect him as he was attempting to touch Resident #6 on her hands and legs and she told him to stop. She stated Resident #6 was cognitively intact and was not physically able to defend herself. When interviewed on 1/24/2018 at 2:15 PM, LPN #4 stated Resident #2 was inappropriate to staff and residents. She stated she had to keep an eagle eye on him and was afraid he was going to try something with another resident. She stated it was difficult to watch him on the evening shift as there were usually 3 CNAs and she was usually the only nurse for the entire unit. She stated he was on 15 minute checks and it was difficult to keep track of him when she passed medications on the other hall. She stated he got around fast and could get in and out of his wheelchair by himself. She stated when she was leaving the other night, she saw him wheel himself out of his room and into the room next door that 2 ladies occupied. She said the CNA went right in behind him and took him out. She stated it only took a few seconds and could have easily gone undetected. When interviewed by phone on 1/26/2018 at 8:25 AM, LPN #3 stated she was working on 12/21/2017 and 1/18/2018 when both incidents between Resident #1 and 2 happened, and did not witness either one. She stated it was hard to tell who instigated the incidents and whenever she saw them near each other, she would separate them. She stated Resident #2 was on 15 minute checks a couple of times, his behavior would subside, he would be taken off the checks, and something else would happen. She stated other residents were not safe around Resident #2. She stated Resident #7 was defenseless and he often tried to get close to her and touch her, and staff would intervene. She stated the other night he wheeled out of his room at change of shift and into Resident #7's room. She stated he was always wanting to touch and made rude comments to staff and residents. She stated Resident #6 told her that Resident #2 made comments that made her feel uncomfortable and he tried to touch her. She stated it was difficult to keep an eye on him and she tried to keep him close to her when she was passing medications. She stated he had to be shooed away from female residents and specifically mentioned Residents #3, 7, and another female. She stated he went up and down the hall after female residents and when she turned her back for a minute, he would be scooting up to someone else. She stated he required more than 15 minute checks and needed to be kept occupied. When interviewed on 1/26/2018 at 9:40 AM, Resident #6 stated Resident #2 made her feel very uncomfortable with his comments. She stated he told her he wanted to hug and kiss her, and usually only said things when others were not around. She also stated he had been in the room with Resident #1, her former roommate, and she had to ring the call bell for a CNA to take him out. When interviewed on 1/26/2018 at 11:15 AM, RN #1 Unit Manager stated Residents #1 and 2 were put on 15 minute checks after the incident on 12/21/2017. She stated Resident #2 had a history of [REDACTED]. She stated his 15 minute checks were discontinued as he was doing better. When shown and asked about the nursing note on 12/27/2017 regarding the resident's behavior with several female residents in the dining room, she stated she was concerned as to how the resident got around like that with staff present. She then stated the LPN was spoken to about the incident. She stated she was concerned about him being around female residents in a verbal sense and explained he said things that female residents might take personally. She was not worried about physical behavior as the staff kept him busy. She then stated he was on 15 minute checks as they needed to protect female residents. When interviewed on 1/26/2018 at 12:10 PM, the physician stated he was aware of the 2 sexual incidents that took place between Residents #1 and 2. He stated he was told Resident #1 was responsible for the incidents and he was not aware of any of Resident #2's behaviors towards other residents. When interviewed on 1/26/2018 at 12:30 PM, the DON stated she was not aware Resident #2 was sexually inappropriate to staff or any residents prior to the incident on 12/21/2017. She stated when she investigated incidents, she drew her conclusions from the wittness statements and progress notes and did not conduct interviews. When she reviewed the resident's medical record with the surveyor, she stated she was unaware he was inappropriate with staff and unaware he was touching other residents. When he was taken off 15 minute checks on 1/2/2018, she was unaware of any behavioral issues after the incident with Resident #1 on 12/21/2017. She stated if he was touching other residents, it should have been reported. She stated Resident #2 needed to be watched more carefully and more interventions were needed. 2) Resident #1 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired and behavioral symptoms occurred, 1 to 3 days out of 7, included: physical behavioral symptoms directed toward others; verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. The resident's behavioral symptoms significantly interfered with her participation in activities or social interactions, put others at significant risk for physical injury, and significantly disrupted care or living environment. The resident's behavior compared to prior assessment had worsened. The resident required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; she required supervision and setup help only for eating and ambulation. Review of Resident #1's nursing progress notes documented: - On 12/11/2017 at 11:08 PM, the resident was sexually familiar with Resident #2. The residents were separated and she told the nurse to mind your own business. - On 12/21/2017 at 11:10 PM, a certified nurse aide (CNA) reported that Resident #1 had her hands down Resident #2's pants. The facility was asked for all investigations from (MONTH) (YEAR) to present on (MONTH) 23, (YEAR). The facility did not have a documented investigation for 12/11/2017. The facility's investigation and incident report documented on 12/21/2017 at 7:00 PM, in the dining room, Resident #1 was standing next to Resident #2 with her hand inside the back of his pants. The residents were separated and put on 15 minute checks. The physician saw the resident and orders were received to decrease her [MEDICATION NAME], add [MEDICATION NAME] and [MEDICATION NAME] for sexual behaviors. The investigation concluded there had been no previous incident with the two residents and neither resident had a prior incident of this nature. The resident's comprehensive care plan (CCP) was updated on 12/22/2017 documenting the resident had inappropriately touched a male resident, no new interventions were documented. Nursing notes for Resident #1 documented: - On 12/24/2017 at 11:12 PM, the resident would not stay away from Resident #5 and was inappropriate with male staff. - On 1/2/2018 at 11:35 AM, the RN Unit Manager and the Director of Nursing (DON) changed the resident from 15 minute checks to 30 minute checks. - On 1/14/2018 at 6:57 PM, the resident was seen reaching for another resident's (male) groin area and they were separated before contact occurred. - On 1/18/2018 at 6:17 PM, two activity aides saw the resident groping Resident #2 over his pants in his private parts area. The facility's investigation documented on 1/18/2018 at approximately 6:00 PM, Resident #1 was fondling Resident #2 in the groin area. The residents were separated and 15 minute checks were started for both residents. On 1/19/2018 the incident was re-evaluated and Resident #1 was moved to another unit with a limited number of male residents to decrease the potential for recurrence, and continued on 15 minute checks. When interviewed on 1/24/2018 from 9:50 to 10:10 AM, CNA #8 stated Resident #1 was highly inappropriate with other residents. She was sexually inappropriate only with Resident #2 and mean to other residents especially Resident #5. When interviewed on 1/24/2018 from 1:20 to 1:30 PM, LPN #10 stated Resident #1 had a history of [REDACTED]. She also yelled at other residents and called them names. She stated Resident #1 did not like Resident #5 and threatened him with a knife or fork, and she was usually more verbally abusive. She stated Resident #5 was very demented and would not be able to protect himself or even yell for help. When interviewed on 1/24/2018 at 1:45 PM, LPN #5 stated the resident was very drawn to Resident #2 and called a lot of the men her boyfriends. She liked to grab, kiss, and talk dirty to the men; staff tried to keep the men away from her. She stated there was not much more than 15 minute check that could be done. She stated the resident was ambulatory and would probably find another man on the new unit. When interviewed on 1/24/2018 at 2:15 PM, LPN #4 stated Resident #1's main problem was bad language. She stated the resident was physically and verbally mean, and was not sexually inappropriate until her involvement with Resident #2. She stated 15 minute checks were not working as both residents could get around easily. She stated she was glad they finally moved the resident as it was too hard to keep track of both of them. She stated one day Resident #1 punched her in the shoulder. When interviewed on 1/26/2018 at 12:30 PM, the DON stated she was not aware of all Resident #1's behaviors. She stated when she investigated incidents, she drew her conclusions from the statements and progress notes and did not conduct interviews. She stated when the resident threatened another with a knife, an investigation should have been done. She stated there should have been more interventions in place to protect other residents. She stated after the incident on 12/21/2017 with Resident #2, interventions included calling the physician for medication changes and 15 minute checks. She stated the checks were stopped when she seemed to be doing better. She stated after the last incident, they moved the resident off the unit and continued 15 minute checks. 10NYCRR 415.4(b)

Plan of Correction: ApprovedSeptember 12, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Plan of Correction F Tag: 610 Investigate/Prevent/Correct Alleged Violation
The following corrective actions for those resident who have been found affected by the identified practice:
1. Resident #1: On [DATE] this resident was placed on 15 minute checks and the care plan was revised. On [DATE] resident was moved to the 4th Floor in order to separate from Resident #2. The resident expired on [DATE].
2. Resident #2: On [DATE] resident was placed on 15 minute checks and the care plan was revised. On [DATE] the Regional Director of Memory Care completed an independent review and shared recommendations with the IDCP Team. On [DATE] the facility held an IDCP Team meeting to review all of the residents; progress notes, behaviors and plan of care. The Regional Director of Memory Care completed an independent review and shared recommendations with the IDCP Team. The care plan was revised to include: Communication techniques when inappropriate language or behaviors occurred. On [DATE] the care plan was revised to reflect that the resident was not to sit with female residents at meals or activities. It was determined appropriate interventions are in place to prevent reoccurrence.
The following corrective actions will be implemented to identify other residents that may be affected by the same practice:
1. All residents have the potential to be affected. Progress notes, for Resident #2. from (MONTH) (YEAR) to (MONTH) (YEAR) were reviewed by the DON to ensure there are no other occurrences of abuse, neglect or mistreatment that have not been thoroughly investigated. Any identified occurrences will have a thorough investigation completed by interviewing pertinent staff and reviewing the resident behavioral histories. Measures will be put place to prevent reoccurrence or to provide protection to other vulnerable residents while the investigation is occurring.

The following measures will be implemented to assure continuing compliance with regulations:
1. All nursing staff were re-educated by the Clinical Educators on the facilities policy title Abuse Prevention, Identification, Investigation, Protection and Reporting.
2. All staff responsible for conducting investigations will be re-educated by the DON on how to conduct a thorough investigation which will include interviews with staff, a review the medical record, a review of behavioral histories, developing measures to protect residents while investigations are in progress and to develop plans to prevent reoccurrence. An investigation check list will be implemented to ensure all steps of the investigation are completed thoroughly.
3. Progress notes and 24 hour reports will be reviewed by the Supervisor and Unit Mangers daily to ensure all alleged incidents of abuse, neglect or mistreatment are identified and investigated timely.

The facility?s compliance will be monitored utilizing the following quality assurance system:
1. The DON/ADON will conduct an audit on [DATE] to ensure compliance. Progress notes will be reviewed to ensure investigations are thoroughly conducted, as indicated. Additionally, to ensure continued compliance the DON/ADON will conduct audits for period of 3 months or until 100% compliance is achieved.
2. The Director of Nursing will compile statistical data on a monthly basis. Trend analysis data will be presented to the QAPI Committee and reported to the QA Committee for evaluation and recommendations for improvement as needed.
Responsibility Team:
Primary Responsible individual ? Director of Nursing - Work Team: Nurse Managers, Nurse Educator and Assistant Director of Nursing.
Completion Date:
[DATE]