Monroe Community Hospital
August 8, 2018 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: Potential to cause more than minimal harm
Citation date: August 8, 2018
Corrected date: September 27, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 262) completed on 8/8/18, it was determined that for one of three residents reviewed for abuse, neglect, or mistreatment, the facility did not ensure the residents were free from abuse. The issue involved an alleged non-consensual sexual contact between a visitor (posing as a volunteer) and Resident #4. This is evidenced by the following: The undated facility policy, Department of Volunteer and Customer Services included that all volunteers must wear an identification (ID) badge at all times, no exceptions (place on upper left chest for high visibility), ladies wear a smock or cobblers apron, and men wear a vest provided by the facility. Volunteers may not provide direct nursing functions (lift or transfer residents, give medication, or feed residents). The undated facility policy, Abuse Prohibition Program included investigation guidelines for abuse, neglect, and mistreatment. Sexual abuse is defined as including, but not limited to, sexual harassment, sexual coercion, or sexual assault. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/11/18, revealed that the resident had severely impaired cognition and was totally dependent on staff for all care. The Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Care Kardex, updated on 6/25/18, included to have the resident out of bed for volunteer by 8:00 a.m. The resident sign-out sheets, from (MONTH) (YEAR) to current (not a complete record, some time is missing), revealed the volunteer, signed his own first name as the responsible party and signed the resident off the unit on an almost daily basis. Review of the facility Incident/Accident Report, dated 7/20/18, revealed that on 7/20/18 at 12:50 p.m., the Licensed Practical Nurse (LPN) walked into the resident's room and observed a visitor that she thought was a volunteer kissing the resident on the mouth with one hand on the resident's chest and the other hand on the lower abdomen. The LPN documented that she observed the resident pushing back from being kissed. When the volunteer realized the LPN was in the room, he quickly stopped kissing, fixed his and the resident's hair, and told the resident he would see him the next day. The LPN told the volunteer that this was not the end of that, and he left the room quickly, exiting the building by the stairs. Review of the facility Investigative Report, dated 7/23/18, revealed when questioned and assessed by a Registered Nurse and physician, the resident stated he had been kissed by the volunteer. When asked if he was touched, the resident said yes and pointed to his genital area. The physician repeated the questions three times during the examination and the resident answered the same each time, that he had been touched yes, on my dick. Statements from staff included that the volunteer was always seen in street clothes by two staff, was seen in a blue volunteer vest by three staff, and was seen in street clothes at times and a blue vest at times by two staff. Whether or not the volunteer was wearing an ID badge was not documented in any of the statements. The facility concluded that the volunteer was not a volunteer with the facility but was a family member of another resident on another unit and that non-consensual sexual activity had occurred. The investigative report included that the police were notified of the incident on 7/20/18 following the physician assessment. Review of the physician progress notes [REDACTED]. The family was notified at that time by the physician and the Social Worker, and the resident was transferred to the hospital. Review of a progress note, signed by the LPN and dated 7/20/18 at 11:00 p.m., included that the resident returned from the hospital in good spirits and had no complaints. When interviewed on 7/31/18 at 8:30 a.m., the Deputy Director and the Administrator stated that their conclusion was that the visitor was posing as a volunteer and was the family of another resident. They said that the family had met the volunteer, knew he was visiting, and did not object. Interviews conducted on 8/2/18 included the following: a. At 9:55 a.m., the Supervisor of Volunteer Services said the volunteer was not a volunteer and had never applied to become one. He said that a Leisure Service Aide had told him that the resident had a visitor that was spending a lot of time with him and should become a volunteer. The Supervisor said that volunteers should never be behind closed doors with residents, should always wear a blue vest, and an ID badge. He said that on the security video footage on 7/20/18, the volunteer was not wearing a vest or an ID badge. He said he has never seen the volunteer wearing a vest. He said the volunteer vests and ID badges are kept in a locked room secured with a keypad entry. b. At 12:53 p.m. during the interview, Resident #4 denied and could not recall inappropriate physical or sexual contact by the volunteer. c. At 1:15 p.m., the CNA said she was told by nurses that the resident had a volunteer in the morning and that she was to have the resident ready for the visit. She said she saw the volunteer almost daily for about a year and could not remember what he was wearing. d. At 1:33 p.m., the Registered Nurse (RN) Manager stated that the resident was transferred to this unit about (MONTH) (YEAR) and she was told at that time that the resident had a volunteer. She said the volunteer introduced himself as a volunteer and was wearing a blue vest but she did not notice whether or not the volunteer was wearing an ID badge. e. At 2:11 p.m., the Leisure Service Aide said she saw the volunteer with his family member who was a resident on another floor and with Resident #4 many times for just under a year. She said she saw the volunteer with Resident #4 in activities such as bingo and music, outside walking or sitting, and in the sixth floor lounge playing air hockey or watching television. She said she always saw the volunteer wearing street clothes and never wearing a vest or an ID badge. She said she recommended to the Supervisor of Volunteer Services to recruit the individual as a volunteer because she knew he was not a volunteer. When interviewed by telephone on 8/3/18 at 11:02 a.m., the LPN stated that on 7/20/18 at approximately 12:37 p.m., she entered the resident's room to give him medications. She said the resident was in the second bed and the privacy curtain was half way closed. She said since her hands were full, she did not knock but called out, Knock, knock. The LPN said she saw the volunteer kissing the resident. She said his right hand was on the resident's chest and his left hand was lower on the resident's body near his stomach above his genitals. The LPN said the resident was trying to pull his head away from being kissed. She said when the volunteer realized she was in the room, he quickly stopped kissing the resident, fixed his and the resident's hair, and told the resident he would see him the next day. The LPN said she told the volunteer that this was not the end of that, and he left the room quickly, exiting the building by the stairs. She said the volunteer was not wearing a vest or ID badge and she never thought he was a volunteer because they wear vests. The LPN said she had only worked on the unit for about four months, and she questioned other staff about why the volunteer spent time in the bathroom with the resident with the door closed. The LPN said she was aware the volunteer was shaving the resident and brushing his teeth but never actually witnessed it because the bathroom door was closed. The LPN said she was told that the volunteer helps the resident everyday. Interviews conducted on 8/6/18 included the following: a. At 9:53 a.m., the Quality Improvement Manager/Abuse Coordinator stated that review of the security video on 7/20/18 revealed the volunteer leaving the unit and he was not wearing a vest. She said she thinks that once the staff got to know the volunteer, they did not necessarily look for a vest. She said in her investigation, she concluded that the resident had been visited by that volunteer for about two years. b. At 10:37 a.m., the RN Clinical Nurse Manager stated that as long as she can remember, the volunteer visited the resident. She stated she never discussed with the family that the resident had a volunteer. She said the Social Worker (SW) would have done that. c. At 11:30 a.m., the SW stated that she was under the assumption that the volunteer was really a volunteer but she had never met him. When interviewed by telephone on 8/8/18 at 10:20 a.m., the resident's family member stated that the volunteer had introduced himself to the family as a volunteer about three months prior to the alleged incident. The family member said they saw the volunteer several times but never saw him wearing a vest or ID badge. The family member said they were aware that the volunteer was providing personal care such as shaving but was not aware that was not allowed. The volunteer was not available for interview. (10 NYCRR 415.4(b)(1)(i))

Plan of Correction: ApprovedAugust 24, 2018

F600
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 22, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 22, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The resident question received a full medical evaluation (both on site and hospital) and did not display any negative effects from the incident. Moreover, the resident?s plan of care will be revised to include volunteer involvement if applicable. The Facility will also implement new parameters and guidelines for volunteers designed to prohibit non-volunteers from serving as volunteers.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The Facility will conduct an audit to determine if any other residents are being served by persons claiming to be volunteers but who are not recognized by the Facility as volunteers and have not completed volunteer training
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Volunteer Coordinator is responsible for the selection, screening, and training of all volunteers. Volunteers must be registered as such through the Volunteer Office and must have completed training before being allowed to be assigned to a resident as a volunteer. The Facility will conduct an audit for all residents to determine who may have an assigned volunteer. The Volunteer Coordinator shall maintain a current listing of all current volunteers and distribute that list to the nursing units and Social Services monthly. Residents who have been assigned volunteers will have the role of the volunteer included in the plan of care. The Volunteer Coordinator will provide in-service training to both volunteers and unit staff to insure there is an understanding of the volunteer parameters and guidelines.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance and Improvement Coordinator shall appoint a committee of at least three persons who will monitor and audit the (a) completion of volunteer training for both volunteers and staff, (b) verify the initial and ongoing completion of volunteer assignment audits, and (c) verify the participation of a volunteer is included in all applicable resident plans of care. Once initial audits have been completed audits will be conducted on a quarterly basis for one year and annually thereafter. The committee shall also conduct audits on a monthly basis to insure a current list of volunteers has been distributed to the nursing units and Social Services. Results of the auditing will be reported at each appropriate QAPI meeting.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
September 27, (YEAR)
Volunteer Coordinator

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 8, 2018
Corrected date: September 27, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 262) completed on 8/8/18, it was determined that the facility did not ensure a thorough and complete investigation for one of three residents reviewed for allegations of abuse, neglect, or mistreatment. Specifically, the facility did not identify the root cause analysis of an incident of alleged non-consensual sexual contact with Resident #4, and the facility did not provide preventive follow-up with corrective measures to prevent further incidents. This is evidenced by the following: The undated facility policy, Abuse Prohibition Program, directed investigation guidelines for abuse, neglect, and mistreatment. Sexual abuse is defined as including, but not limited to, sexual harassment, sexual coercion, or sexual assault. Supervisory staff will work with their respective department heads to develop ways to identify and prevent inappropriate behavior, and staff shall periodically be provided in-service training accordingly. Investigations which may result in findings that indicate an egregious action on the part of an employee or other person may be subject to further investigation as determined by the Abuse Coordinator and/or Executive Director. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/11/18, included that the resident had severely impaired cognition and was totally dependent on staff for all care. Review of the 7/20/18 facility Incident/Accident Report revealed that on 7/20/18 at 12:50 p.m., a Licensed Practical Nurse (LPN) walked into the resident's room and observed a visitor that she thought was a volunteer, kissing the resident on the mouth with one hand on the resident's chest and the other hand on his lower abdomen. The LPN documented that she observed the resident pushing back from being kissed. When the volunteer realized the LPN was in the room, he quickly stopped kissing, fixed his and the resident's hair, and told the resident he would see him the next day. The LPN told the volunteer this was not the end of that, and he left the room quickly, exiting the building by the stairs. Review of the 7/23/18 Facility Investigative Report revealed when questioned and assessed by a Registered Nurse and physician, the resident stated he had been kissed by the volunteer. When asked if he was touched, the resident said, Yes, and pointed to his genital area. The physician repeated the questions three times during the examination, and the resident answered the same each time, that he had been touched yes, on my dick. Statements from staff included that the volunteer was always seen in street clothes by two staff, was seen in a blue volunteer vest by three staff, and was seen in street clothes at times and a blue vest at times by two staff. Whether or not the volunteer was wearing an ID badge was not documented in any of the statements. The facility concluded that the volunteer was not a volunteer with the facility but was a family member of another resident on another unit and that non-consensual sexual activity had occurred. When interviewed on 7/31/18 at 8:30 a.m., the Deputy Director and the Administrator stated that they had conducted a thorough investigation and there was nothing else to do now because the volunteer had passed away. When interviewed on 8/2/18 at 9:55 a.m., the Supervisor of Volunteer Services said he assumed employees know how to identify volunteers and their roles. He said he plans on adding that information to orientation for new employees. When asked about current staff, he said he plans to do education with the Unit Managers in the near future so hopefully this does not happen again. Interviews conducted on 8/6/18 included the following: a. At 9:53 a.m., the Quality Improvement Manager/Abuse Coordinator stated that she does not see any documentation that the staff interviewed about the incident were asked about the volunteer wearing an ID badge. She said that was a good education point to look at but that they did not investigate about the ID badge. She said that the new employee orientation will include what volunteers can and cannot do and what they should be wearing. When asked if anything has been done to in-service current employees, she said no, but that was a good idea. The Quality Improvement Manager/Abuse Coordinator said that this was the first time she has encountered a problem with an individual posing as a volunteer. She said she was not aware of anyone else doing that, but nothing else has been done to investigate whether or not anyone else could be posing as a volunteer. The Quality Improvement Manager/Abuse Coordinator said staff on Hope 3 and Hope 4 have a heightened awareness about volunteers now but that nothing has been done with other staff. She said they could have checked the current volunteers to be sure they were all really volunteers, but she is not aware of anyone doing that. b. At 12:07 p.m., the Director of Volunteers stated that on 8/1/18 (after surveyor started survey on 7/31/18), he had received an email regarding the incident and had changed the volunteer policy to reflect that volunteers cannot provide personal care for residents. He said he also sent out emails to the Nurse Managers to meet and discuss volunteers but as of 8/6/18, no meetings had occurred. (10 NYCRR 415.4(b)(3))

Plan of Correction: ApprovedAugust 24, 2018

F610
In direct response to the questions listed in the correspondence from NYSDOH dated (MONTH) 22, (YEAR) and received by the Facility via DOH HCS Portal Link transmittal on (MONTH) 22, (YEAR), along with the Statement of Deficiencies, the Facility offers the following:
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The resident in uestion received a full medical evaluation (both on site and hospital) and did not display any negative effects from the incident. Moreover, the resident?s plan of care will be revised to include volunteer involvement if applicable. The Facility will also implement new parameters and guidelines for volunteers designed to prohibit non-volunteers from serving as volunteers. At the time the incident was discovered the Facility contacted the alleged perpetrator and prohibited him from visitation pending the outcome of the investigation (both Facility and Rochester Police). The next day the Facility was informed the alleged perpetrator had passed away.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The Facility will conduct an audit to determine if any other residents are being served by persons claiming to be volunteers but who are not recognized by the Facility as volunteers and have not completed volunteer training
3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur?
The Volunteer Coordinator is responsible for the selection, screening, and training of all volunteers. Volunteers must be registered as such through the Volunteer Office and must have completed training before being allowed to be assigned to a resident as a volunteer. The Facility will conduct an audit for all residents to determine who may have an assigned a volunteer. The Volunteer Coordinator shall maintain a listing of all current volunteers. Residents who have been assigned volunteers will have the role of the volunteer included in the plan of care. The Volunteer Coordinator will provide in-service training to both volunteers and unit staff to insure there is an understanding of the volunteer parameters and guidelines.
In-service will also be provided to other Facility staff about the new guidelines for volunteers.
The in-service training sessions will have special focus on the importance of properly identifying volunteers. The Volunteer Coordinator, who is new to the long term care industry, will also receive education regarding the importance of urgency and providing training in a timely manner. Volunteer guidelines will also be incorporated into new employee orientation as well as annual in-service training regarding volunteers.
The Abuse Coordinator shall review the template the Facility uses as a guide for its investigations to insure that a ?determination of root cause? is included in the template. Other revisions will be made to the template as may be deemed necessary.
4. How will the corrective action be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice?
The Quality Assurance and Improvement Coordinator shall appoint a committee of at least three persons who will monitor and audit the (a) completion of volunteer training for both volunteers and staff, (b) verify the initial and ongoing completion of volunteer assignment audits, and (c) verify the participation of a volunteer is included in all applicable resident plans of care. Once these initial audits have been completed audits will be conducted on a quarterly basis for one year and annually thereafter. The committee will also verify and audit (1) the completion of training for the Volunteer Coordinator, (2) the inclusion of volunteer guidelines in new employee orientation, and (3) the scheduling of annual in-service training regarding volunteers. Results of the auditing will be reported at each appropriate QAPI meeting.
5. The date for correction action and the title of the person responsible for correction of this deficiency.
September 27, (YEAR)
Quality Assurance (Abuse) Coordinator