1119:2018 Nursing Home Inspection Details ?apartment NYS Health Profiles Of Health Find and Compare New York Health Care Providers FF11 Comprehensive Care Plan REGULATION: 0483.21(b) Comprehensive Care Plans 0483.21 The facility must develop and implement a comprehensive person?centered care plan for each resident, consistent with the resident rights set forth at and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and needs that are identi?ed in the comprehensive assessment. The comprehensive care plan must describe the foliowing - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and well-being as required under 0483.24, 0483.25 or 0483.40; and (ii) Any services that would otherwise be required under 0483.24, 0483.25 or 0483.40 but are not provided due to the resident's exercise of rights under 0483.10, including the right to refuse treatment under Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)ln consultation with the resident and the resident's representative(s)? (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph of this section. Scope: Isolated Severity: Potentialjo cause more than minimal harm Citation date: June 15, 2018 Corrected date: August 8, 2018 TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT Based on record review and staff interviews conducted during a Partial Extended survey (Complaint NY 780) completed on 6/15/18, the facility did not developed and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident?s medical, nursing, and mental and needs that are identi?ed in 1i34 I Hall?U IU mummy UULHIIE the comprehensive assessment for one (Resident of three residents reviewed. Speci?cally, Resident #1 did not have a care plan for elopement that included measurable goals. The facility did not implement appropriate interventions and supervision to ensure the resident's safety. The ?nding is: 1. Resident #1 was admitted to the facility on with The Minimum Data Set (MDS- a resident assessment tool) dated 5/3/18 documented the resident had severe cognitive impairment, usually understands and was understood. Review of the facility's policy entitled Prevention of Elopement and Wandering Protocol last revised on 2/8/18 included but was not limited to the following specifications: The Wander/ Elopement Assessment tool will be initiated by the RN upon resident admission. The discussion of the care planning team will be documented on the Wander/ Elopement Risk Assessment/ Scoring Tool and signed by the RN (registered nurse) completing the risk assessment. Indicators of wandering or elopement behavior include: Resident has a new onset of repetitive verbalizations of I'm going home and is ambulatory. All residents identi?ed to have unsafe wandering or to be at risk for elopement will have speci?ed in their care plan a method to observe the resident's whereabouts. All residents' whereabouts are monitored as per each resident's individualized plan of care. The Interdisciplinary Care Plan last updated on 5/30/18 revealed the resident had no care plan developed for elopement that included measurable goals. An undated Closet Care Plan (CCP, used by staff to provide care), identified as current documented the resident was independent in transfer and ambulation. The GOP does not include the resident was at risk for elopement. Review of a Risk of Elopement Assessment form and the Resident Admission Evaluation dated 4/26/18 and completed by Registered Nurse (RN) Third Floor Unit Manager #2 revealed the resident was at risk for elopement. The form documented the interventions included door alarms and locked elevator (unable to access elevator without code). The assessment tool did not include documentation of the discussion of the care planning team. RN #2 documented on the initial admission assessment the resident was agitated, could not relax, was uncooperative and refused to take his coat off. Review of a Social Work Progress Note dated 4/26/18 written by Social Worker (SW) #2 revealed the resident was alert and oriented with confusion. The resident had been living in a homeless shelter and had no home. The resident was ?xated on money and not wanting to be in the facility. Review of Nursing Progress Notes revealed the following: - 4/28/18 at 3:00 PM written by Licensed Practical Nurse (LPN) the resident had refused all hands- on care, blood pressure and medications. The resident stated, I'm going out of here. - 4/29/18 at 3:00 PM written by LPN the resident had refused all medications and stated, I want to get out, I did not sign myself in here, I'm not a prisoner. Review of a Evaluation dated 5/24/18 written by Nurse Practitioner (NP) #2 revealed the resident was seen today for an initial consultation at staff request. The resident refuses to attend to his personal hygiene and spends most of the day in his room watching TV with his coat on. The resident reported he was angry because he felt he was being held prisoner in the facility. Resident stated, I'm doing 2/34 11/9/2018 Nursing Home Inspection Details bad because I can't go anywhere. I can't go to the bank or store. I can only watch TV all day. I didn't do no crime, so I don't know why they hijacked me and put me here. The resident was upset because he has not received his Social Security checks in months and states the facility is holding him against his will and robbing him of his money. A SW note dated 5/30/18 written by SW #2 documented, SW #2 received a call from the hospital attorney with an update on the resident's court appearance (of 5/30/18). She (the attorney) noted the resident tried to escape every chance he got but his escort was able to re-direct him. For his next court date, they would like to hold it within the facility to avoid this happening again. Review of a Report of Concern form dated 5/31/18 signed by the Maintenance Director and Maintenance Supervisor revealed the document was a report of concern for Resident The report stated the maintenance department had installed a total of 10 window stops (bolts) since the resident's arrival. Maintenance had done an investigation and could not find how they were removed. Upon interview with the resident, the resident stated that he was not aware of what a window stop was or where it was located. The resident swore at the maintenance staff and stated, I can do whatever I want. Maintenance proceeded to put another window stop in his window while the resident was out of the room. The Maintenance Director and Maintenance Supervisor were present for this interview and replacement of window stops. The report of concern also documented that window stops were replaced on the following dates: April 27th, May 3rd, May 7th, May 8th, May 10th, May 12th, May 20th, May 22nd, May 24th and May 31st. During an interview on 6/6/18 at. approximately 9:30 AM, the Maintenance Supervisor stated after the resident was admitted he noted a bolt missing from the resident's window during rounds and replaced it. The bolts were replaced 10 times over a 2 to 3- week period. He stated he told his boss, the Maintenance Director of the issue and many times his boss was with him when they replaced the bolts. The Maintenance Supervisor stated the resident rarely was out on the unit and was angry because he felt he was kidnapped. He stated the screens were ripped in the room and resident would throw garbage out of the window. During an interview on 6/6/18 at 10:40 AM, the Maintenance Director stated the bolts (window stops) on the resident's window were replaced 10 times prior to 5/31/18 and he mentioned the concern directly to the Unit Manager of the Third Floor (RN after the sixth time the bolt was replaced. He brought up the issue of the resident's window bolt removal in morning report on 5/8/18 and 5/21/18 with the Administrator, Director of Nursing (DON), RN #2 Unit Manager and the rest of the interdisciplinary team present. The team members told him they would discuss it. The Maintenance Director created a Report of Concern on 5/31/18 and typed it on 6/1/18 to cover himself, because after reporting the issue twice in morning report nothing was being done to address it. The facility's Accident/ Incident (A I) report dated 6/4/18 completed by RN Supervisor #1 revealed she was contacted at 5:52 AM by the range of motion (ROM) aide (CNA there was a homeless person sleeping in the driveway on the right side of the building. Upon RN #1's arrival at the location of the incident, RN #1 observed the resident lying/ sitting on his right side. In the Elopement/ Elopement attempt Investigation section of the A 8 I it was documented the resident had Alzheimer's with early onset. The resident was placed on the Third Floor lock down unit, window were replaced 10 times by Maintenance Supervisor. The report documented the resident was not care planned for an elopement bracelet device. During interview on 6/4/18 at approximately 2:30 PM, RN #2 stated that she completed the elopement risk assessment upon admission and the resident was at risk for elopement. She stated that the elopement care plan that she implemented was for the resident to be on the Third Floor- Iocked unit where the elevator was coded (locked). He frequently stated that he had to go to the bank. He never tried to leave the unit by elevator or stairwell. She was aware that one time the resident was missing bolts from his window, and maintenance replaced the bolts. The brine-Hnm?lm health nu nnv/nursinn hnme/insnection detail/OEDH 3134 . uvIu-v issue was brought up in morning report one time, she does not recall the date. RN #2 denied ever commenting to another RN that the resident's bolts were replaced 10-12 times. She stated that if she had known the resident was removing window bolts she would have moved him to another room. During an interview on 6/5/17 at approximately 3:00 PM, the part time Social Worker (SW stated the resident was irate upon admission to nursing home and needed time to adjust. The resident often stated he wanted to leave. It was brought to the attention of staff in morning report the resident's window bolts had to be replaced approximately 10 times in the last two weeks. The resident ripped the screen and was throwing garbage out of the window. Thereason the resident was removing the bolts was not identified and she did not ask the resident why he removed the bolts. Care planning for the bolt removal would be a nursing issue. During an interview on 6/5/18 at approximately 3:35 PM, the full time SW #2 stated she was familiar with the resident as she did the admission paperwork and follow up. Upon admission the resident was confused, agitated and said he wanted to go home. One time in morning report staff were told the resident had removed more than one bolt from his window. During an interview on 6/7/18 at approximately 10:45 AM, NP #2 NP) stated the resident was referred to her to evaluate for adjustment to the facility. NP #2 was not informed by the nursing home staff the resident had been removing bolts from his window. In addition, NP #2 stated she would have expected the behavior of removing window bolts to be relayed to her, as she would consider this exit seeking behavior and would have recommended every 15-minute checks. During an interview on 6/6/18 at approximately 3:15 PM, the facility Administrator stated he attended morning report every day. He recalled one time in morning report he had heard about the resident removing bolts from his window and throwing garbage out of the window. The Maintenance Director was going to add extra bolts to the window due to the garbage. He believed the issue was being addressed with the extra bolts. He also stated it was normal for a resident with dementia to comment that they want to leave. The Administrator was asked how he ensures problems brought up in morning report were addressed. He stated it was his expectation to keep the information flowing in detail to make a plan for safety. In summary, the facility did not develop a comprehensive care plan for elopement which included monitoring and supervision beyond placing the resident on a locked dementia unit. The IDT staff did not change the care plan after the resident began displaying exit seeking behavior by removing his window bolts multiple times beginning the day after admission 4/27/18. FF11 Planning Process REGULATION: Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include 4f34 11t9i2018 Nursing Home Inspection Details regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Involve the interdisciplinary team, as defined by in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identi?cation of discharge needs. Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. Scope: Isolated Severity: Potential to cause more than minimal harm Citation date: June 20, 2018 Corrected date: August 8, 2018 TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT Based on interview and record review conducted during the Partial Extended survey (Complaint 780) completed on 6/15/18, the facility did not develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preation of residents to be active tners and effectively transition them to post?discharge care for two (Residents 2) of three residents reviewed for discharge planning. Speci?cally, for Resident #1 the facility did not develop and implement a discharge care plan for a resident admitted under temporary guardianship through Adult Protective Services (APS). The resident repeatedly asked to leave the facility and expressed that he felt like he was being held prisoner. Additionally, for Resident #2 the facility did not develop and implement a discharge care plan for a resident residing on a locked unit, who was no longer an elopement risk and was deemed by the physician to have capacity to make their own health care decisions. The ?ndings are: l?Hnn-ffnt-AEIHE Ina-alum nunnufmurcinn dpfailannH 5?34 The Social Workjob description revised 4/1998 documented essential functions of the position included developing and reviewing a plan of care to meet the long and short-term goals of each resident. In addition, to take an active in decisions and procedures regarding discharge or transfer of residents to another care level. 1. Resident #2 was admitted to the facility's locked dementia unit on 9/5/17 with The MDS dated documented the resident was moderately cognitively impaired, understands and was understood. The Risk of Elopement Assessment dated and signed 9/5/17 by Registered Nurse (RN) #5 documented the resident was at risk for elopement and a Resident Monitoring Bracelet was applied to the left ankle. An Interval Nurse Practitioner (NP) Note dated 11/2/17 documented, Chief complaint: Depression. Social Work (SW) informed provider that she just left resident's room where he was crying because he didn't know why he was brought here, no one told him he was coming here before it happened. Resident explains to provider that he prefers to take care of himself. He doesn't need anyone to clean him. He says he is lonely and has no one to talk to. The Risk of Elopement Assessment dated 1/29/18 and signed by Third Floor Unit Manager RN #2 documented the resident was NOT at risk for elopement and the Resident Monitoring Bracelet was discontinued. The resident remained on the locked dementia unit. The Resident's Interdisciplinary Care Plan last reviewed 3/6/18 by SW, documented the resident was alert and oriented times three (person, place and time), was independent with decision-making and placement Was considered long term care. Approaches included to orient to facility and unit layout, maintain customary routine (pending discharge back home was crossed out) and allow time to adjust. Social Services Care Plan Progress Note-dated and signed 3/7/18 by SW #2 included the following: -Discharge: significant physical needs/need for supervision and assist with ADL's (activity of daily living) was checked. ~The resident desires to discuss returning to the community on: all assessments or comprehensive assessments only or unknown. There was no selection was checked. 6/34 11/9/2018 Nursing Home Inspection Details -Resident attended the meeting was not checked. Further review of the MDS dated revealed the resident required setup/ supervision for bed mobility, ambulation in room and corridor, eating and personalhygiene. The resident required limited assist of one person for transfers and dressing. Review of Section Q, Participation in Assessment and Goal Setting, Resident ticipated in assessment was checked yes. Discharge Plan, Is active discharge planning already occurring for the resident to return to the community? was checked no. During an interview on 6/12/18 at 10:55 AM, Resident #2 stated, The nursing home hasn't planned my discharge and I wished they would. I miss my freedom, my cat and used to have an atment. I've seen the Social Worker maybe once since I've been here. I've never attended a care plan meeting. lwalk with a'walker but I do everything for myself. During an interview on 8/12/18 at 12:30 PM, ttime SW #1 and full time SW #2 revealed they visit or pop in on Resident #2 but did not document their visits. SW #2 stated although the resident was assessed as no longer an elopement risk on 1/29/18, he remained on the locked dementia unit because there were no private rooms available per his preference. In addition, SW #2 stated, Ijust figured he was long term care because he didn't have family. There are no plans to discharge. During an interview on 8/14/18 at approximately 11:00 AM, NP #2 stated her expectation was that all residents have a discharge plan developed and implemented when safe. 2. Resident #1 was admitted to the facility on with The Minimum Data Set (MDS- a resident assessment tool) dated 5/3/18 documented the resident had severe cognitive impairment, usually understands and was understood. The hospital discharge summary dated 4/26/18 documented the patient had significant cognitive dysfunction, had no family around and lived in homeless shelters. evaluated the patient and he lacked decision making capacity. The patient had guardianship and was stable for discharge to subacute rehabilitation. - . Review of a Social Work Progress Note dated 4/26/18 written by Social Worker (SW) #2 revealed the resident was admitted from the hospital. The resident was alert and oriented with confusion. The resident had been living in a homeless shelter and had no home. The resident was m. nmdnurpinn hnmo/inunnrtinn 7"34 ?xated on money and not wanting to be in the facility. Review of Nursing Progress Notes revealed the following: 4/28/18 at 3:00 PM written by Licensed Practical Nurse (LPN) the resident had refused all hands- on care, blood pressure and medications. The resident stated, I'm going out of here. 4/29/18 at 3:00 PM written by LPN the resident had refused all medications and stated, I want to get out, I did not sign myself in here, I'm not a prisoner. The History and Physical Exam (H 8 P) dated 4/30/18 written by Nurse Practitioner (NP) #1 documented the resident was treated for The resident was seen by and deemed not to have capacity, was homeless prior to his hOSpitalization therefore is now admitted to the dementia unit for long term care. Further review of the Section Participation in Assessment and Goal Setting dated 5/3/18 revealed the resident ticipated in the assessment. There was no family or legally authorized representative that ticipated in the assessment. The MDS documented there was not an active discharge plan for the resident to return to the community. The MDS also documented the resident wanted to be asked about returning to the community on all assessments. Furthermore, the MDS indicated that a referral had not been made to the local contact agency. Review of the Interdisciplinary Care Plan last updated on 5/30/18 by SW #2 revealed under the section entitled Continuum of Care revealed placement is considered long term. The Speci?ed goal on the care plan stated Will adjust to admission as observed and/or verbalized 90 days. A SW note dated 5/1/18 written by SW #1 documented Adult Protective Services (APS) was involved in the resident's care and ?ghting for guardianship on May 30, 2018. SS (Social Services) will continue to be available 1:1 (one to one) as needed. Review of nursing 24-hour reports revealed the following: . 3134 11/9/2018 Nursing Home Inspection Details - 4/26/18- 7:00 AM - 3:00 PM shift: agitated wanting to leave, refused skin check. - 4/29/18- 7:00 AM - 3:00 PM shift: Resident alert with confusion, refused all meds, refused to remove coat, I want out of here. - 5/10/18- 3:00 PM - 11 :00 PM shift: no behavior issues this shift but stated I need to go to bank calmly. During an interview on 6/4/18 at approximately 2:10 PM, CNA #2 stated she worked the 7:00 AM to 3:00 PM shift on the Third Floor. CNA #2 stated the resident had stated he felt as if he was being held captive and wanted to get out to get money from the bank. The resident never tried to leave the unit by the elevator or through the stairwell. The resident appeared more upset after his court appearance on 5/30/18. During an interview on 6/5/17 at approximately 3:00 PM, the ttime Social Worker (SW stated she was assigned to the resident's case along with the full time Social Worker. The resident was irate upon admission to nursing home and needed time to adjust. The resident often stated he wanted to leave. The resident had an upcoming court case regarding guardianship. When asked how often she saw the resident to help assess his adjustment to the facility, she stated she saw him through pop in meetings to follow him which were not always documented. SW #1 stated, it was brought to the attention of staff during morning report that the resident's window bolts had to be replaced approximately 10 times in the last two weeks. The resident ripped the screen and was throwing garbage out of the window. The reason the resident was removing the bolts was not identified and she did not ask the resident why he removed the bolts. Care planning for the bolt removal would be a nursing issue. During an interview on 6/5/18 at approximately 3:35 PM, the full time SW #2 stated she was familiar with the resident as she did the admission paperwork and follow up. Upon admission the resident was confused, agitated and said he wanted to go home. SW #2 contacted APS who was pleased with the care. The resident had a temporary guardian and process was in place to make APS the permanent guardian. During further interview on 6/7/18 at approximately 2:stated APS makes all the decisions regarding discharge. Social Work can't make any discharge plans until the permanent guardian is appointed. Social work was in a holding pattern regarding discharge plans until the permanent guardian was appointed. During a telephone interview on 6/11/18 at 3:45 PM, the APS supervisor stated the resident was assigned a caseworker at APS to carry out temporary guardianship duties.The APS supervisor stated that a temporary guardian may approve a discharge plan from an SNF, if they deem it safe and appropriate. Inna-?Hh nunnufnlr?rinr?l hnma/inenar?finn dntail/OFDH 9?34 . . Hummus; FF11 of Accident Hazards/SupervisionlDevices REGULATION: 0483.25(d) Accidents. The facility must ensure that - The resident environment remains as free of accident hazards as is possible; and resident receives adequate supervision and assistance devices to prevent accidents. Scope: Isolated Severity: Immediate jeopardy to resident health or safety Citation date: June 15, 2018 Corrected date: August 8, 2018. TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT Based on observation, interview, and record review conducted during the Partial Extended survey (Complaint NY 780) completed on the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and failed to have a system in place to effectively respond to signi?cant reported concerns for one (Resident of ?ve residents reviewed for accidents. Speci?cally, the facility failed to implement appropriate interventions and supervision to ensure the resident's safety, when the Director of Maintenance reported to an Interdisciplinary Team (IDT) that a resident repeatedly removed screws that prevented the window in his room from opening beyond 6 inches. Subsequently, on the resident fashioned a rope from clothing, opened the window in his third-?oor room, attempted to climb out and fell to the ground. The resident expired enroute to the hospital. This resulted in IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE 12l34 11(9i2018 Nursing Home Inspection Details with actual harm to Resident #1 and the potential for serious harm to resident health and safety. The finding is: 1. Resident #1 was admitted to the facility on with The Minimum Data Set (MDS- a resident assessment tool) dated documented the resident had severe cognitive impairment, usually understands and was understood. Review of the facility's policy entitled Prevention of Elopement and Wandering Protocol last revised on included but was not limited to the following specifications: The Wander! Elopement Assessment tool will be initiated by the RN upon resident admission. The discussion of the care planning team will be documented on the Wander/ Elopement Risk Assessment! Scoring Tool and signed by the RN (registered nurse) completing the risk assessment. Indicators of wandering or elopement behavior include: Resident has a new onset of repetitive verbalizations of I'm going home and is ambulatory. All residents identified to have unsafe wandering or to be at risk for elopement will have specified in their care plan a method to observe the residents' whereabouts. All residents' whereabouts are monitored as per each resident's individualized plan of care. The hospital Discharge Summary dated documented the patient had significant cognitive dysfunction, had no family around and lived in homeless shelters. evaluated the patient and he lacked decision making capacity. The patient had guardianship and was stable for discharge to subacute rehabilitation. Review of a Risk of Elopement Assessment form and the Resident Admission Evaluation, completed by the Registered Nurse (RN Third Floor Unit Manager dated revealed the resident was identified at risk for elopement. The Assessment documented the interventions included door alarms and locked elevator (unable to access elevator without code). The assessment tool did not include documentation of discussion with the care planning team. RN #2 documented on the initial admission assessment that the resident was agitated, could not relax, was uncooperative and refused to take his coat off. Review of a Social Work Progress Note, written by Social Worker (SW dated revealed the resident was admitted from the hospital. The resident was alert and oriented with confusion. The resident had been living in a homeless shelter and had no home. The resident was ?xated on money and not wanting to be in the facility. hung-?nun?tnn nu nnul?nnrninn - 13334 . . nun-n.- Review of Nursing Progress Notes revealed the following: at 3:00 PM written by Licensed Practical Nurse (LPN the resident refused all hands- on care, blood pressure and medications. The resident stated, I'm going out of here. - at 3:00 PM written by LPN #1 the resident had refused all medications and stated, I want to get out, I did not sign myself in here, I'm not a prisoner. The History and Physical Exam (H P), completed by the Nurse Practitioner (NP dated documented the resident was treated for The resident was seen by and deemed not to have capacity, was homeless prior to his hospitalization therefore is now admitted to the dementia unit for long term care. The also documented the resident was alert with mood and affect congruent. The Interdisciplinary Care Plan, last updated on revealed the resident had no care plan developed for elopement that included measurable goals. In addition, the care plan documented the resident was non-compliant with personal care including showers, grooming, oral care, dressing and clothing changes. The resident refused medications, treatments and labs (blood work). The care plan also documented the resident believed he was in jail, self-isolated himself, and preferred to keep his door shut. The care plan did not include a method to observe the resident's whereabouts. A Evaluation, completed by NP dated revealed the resident had a documented history of and was being seen for an initial consultation at the staff's request. The resident was previously homeless and deemed to lack capacity while hospitalized therefore was placed in long term care. The resident reported he was angry because he felt he was being held prisoner in the facility. The resident stated, I'm doing bad because I can't go anywhere. I can't go to the bank or store. I can only watch TV ?all day. I didn't do no crime so I don't know why they hijacked me and put me here. The resident was upset because he had not received his Social Security checks in months and stated the facility was holding him against his will and robbing him of his money. During the evaluation the resident told NP #2 to get out of the room. NP #2 documented the resident's verbal aggression continued to escalate so she concluded the consultation. NP #2?s assessment was The treatment recommendation stated the resident was unlikely to be agreeable to medication management. Furthermore, if the resident became a danger to self and/or others, send to emergency detment (ED) for evaluation and stabilization. Review of a Report of Concern form for Resident signed by the Maintenance Director and Maintenance Supervisor, dated revealed 111?91?2018 Nursing Home Inspection Details the maintenance detment had installed a total of 10 window stops (bolts) since the resident's arrival. Maintenance had done an investigation and could not find how they were removed. Upon interview, the resident stated that he was not aware of what a window stop was or where it was located. The resident swore at the maintenance staff and stated, I can do whatever want. Maintenance proceeded to put another window stop in his window while the resident was out of the room. The Maintenance Director and Maintenance Supervisor were present for this interview and replacement of window stops. The report of concern also documented that window stops were replaced on the following dates: and Review of the nursing 24-hour reports dated from to revealed the resident appeared on the reports because he was a new admission to the facility. There was no documentation of the resident removing bolts from his windows through Most of the nursing notations on the report were related to the resident refusing medications and hands on care. The resident did not appear on the 24-hour reports from through Review of a Nursing Progress Notes, written by LPN dated 18 at 7:00 AM revealed she was informed by the ambulation aide (CNA that the supervisor needed her assistance outside in the back of the building and that one of her residents had eloped out of the window. When LPN #2 arrived outside, she saw the resident sitting] slumped next to the wall on the side of the building. The resident was mumbling but she was unable to hear what he was saying. The Supervisor (RN was on the scene, did a quick assessment, and called 911. LPN #2 documented that she ran inside to call CNA #10 for assistance and obtained paperwork for EMS (emergency medical services) and the police. The resident's guardian was called at approximately 7:00 AM and a message was left. Review of an Accident/ Incident (A I) report, completed by the RN Supervisor, dated revealed she was contacted at 5:52 AM by the range of motion (ROM) aide (CNA who was coming in for the 6:00 AM to 2:00 PM shift. The ROM Aide (CNA stated there was a homelessperson sleeping in the driveway on the right side of the building. Upon arrival at the location of the incident, RN #1 observed the resident lying/ sitting on his right side. The resident was alert and responsive. He was attempting to get up, and going from a lying to a sitting position. The resident verbalized to staff he wanted someone to hold his hand. RN #1 called 911 and was instructed not to touch the resident. RN #1 noted a gross amount of blood coming from either the right or left foot. Upon arrival to the scene, the emergency responders cut the resident's socks off both feet. A large laceration was noted on the right heel and the right great toe. Upon observing the scene, RN #1 documented that she noted a man-made rope with multiple articles of clothing tied together hanging from a Third Floor window. The rope - extended all the way to the ground with clothing extending out from the building. The Elopement] Elopement Attempt Investigation section of the A documented the resident had Alzheimer's with early onset. The resident was placed on the Third Floor lock down unit and window were replaced 10 times by Maintenance Supervisor. The resident was last observed at 4:30 AM by CNA #10, at which time the resident was awake sitting on the side of the bed in his room. The report documented that the resident was not care planned for an elopement bracelet device. . Review of employee written statements related to the investigation revealed an undated statement by the Maintenance Supervisor which stated, on Thursday he put window stops in the resident's room. This was about the 10th time the stop had been replaced. nunnuinnrcinn hnmel?insnentinn 15?34 . .5 . Hun?ulna During an interview at this time, the Maintenance Director stated, he replaced the missing widow nuts and bolts this morning, after the resident's fall. He had recently installed four nuts and bolts because the resident had removed them. The Maintenance Director did not know how the resident removed them. He suspected the resident may have used a butter knife from his most recent meal. He did not find any tools or butter knives in the resident's room. He did not know if anyone searChed the resident's pockets after the fall. This resident usually stayed in his room and was not known to try to leave through exit doors or elevator. During an interview on at approximately 9:30 AM, the Maintenance Supervisor stated after the resident was admitted he noted a bolt missing from the resident's window during rounds and replaced it. The bolts were replaced 10 times over a 2 to 3 week period. He stated he told his boss, the Maintenance Director of the issue and many times his boss was with him when they replaced the bolts. The resident denied any knowledge of howl why the bolts were missing. Usually when they had to replace the bolts the CNA (certified nurse aide) would distract the resident and get him out of the room so they could replace the bolts. The Maintenance Supervisor and his boss had searched the resident's room to see if resident had tools to remove bolts and none were found. The last time the bolts were replaced was on During an interview on at 10:40 AM, the Maintenance Director stated he spoke directly to the Unit Manager of the Third Floor (RN after the sixth time the bolt was replaced. He brought up the issue of the resident's window bolt removal in morning report on and with the Administrator, Director of Nursing (DON), RN #2 Unit Manager and the rest of the interdisciplinary team present. The team members told him they would discuss it. The Maintenance Director stated'he created a Report of Concern on and typed it on to cover himself, because after reporting the issue twice in morning report nothing was being done to address it. He stated his intention with the Report of Concern was to bring it to morning report on and present the issue again. However, morning report was canceled on due to the team members working on the plan of correction for the recent survey. He gave the Report of Concern to the acting DON on after the incident. Prior to the resident's admission to the room on he assessed the room, the window had one bolt in place and the window screen was intact. He stated after the resident's admission to the room, a large slit was noted in the screen. The last time the bolts were replaced in the window was on Thursday The window was checked again on Friday and the bolts were in place. Review of an ambulance Patient Care Report dated revealed EMS arrived at the scene on at 6:09 AM. When EMS arrived, the patient was sitting upright against a small wall next to driveway at the nursing home. The patient appeared to have tied all his clothes together and created a rope so he could climb out of his Third-Floor window . The patient was awake, and unable to answer any questions, garbled at baseline with dementia. The patient was uncooperative with back boarding and cervical collar application. The patient was assisted to the backboard by the ?re detment and had two lacerations on the right foot with profuse bleeding. The patient was immediately secured to backboard and taken into ambulance. Shortly after, the patient became apneic (suspension of breathing) and pulseless. Compressions were I 16i34 11!9i2018 Nursing Home Inspection Details started immediately, and the fire detment had to be requested back to the scene for assistance. EMTs requested amedic assistance at the time of Paramedics arrived at 6:30 AM. Prior to amedic arrival, the resident was given NAME]-increases cardiac output) via his humerus (arm bone- emergency procedure used when difficulty gaining IV (intravenous) access). The resident was transported to the hospital. Records revealed the resident was intubated (placement of a breathing tube) and de?brillated (treatment for The primary impression per the report was and the secondary impression was trauma related to bleeding. Further review of the ambulance report revealed the estimated time of the ?rst arrest was 6:25 AM with CPR started at 6:25 AM. The ambulance left the scene at 6:49 AM and arrived at the hospital at 6:56 AM. The patient had no pulse upon arrived at hospital and at that time CPR was abandoned] death was 7:00 AM. During an interview on at approximately 11:20 AM, CNA #1 stated on at approximately 5:50 AM she pulled into the facility king lot for her shift that began at 6:00 AM. She saw a man lying on the ground in the king lot and thought it was a homeless person. He was moving around when she saw him and she called the RN Supervisor (RN from her car, who came down immediately. As they approached the man they realized it was a resident. One shoe was on and one was off, the resident's feet were bloody. CNA #1 stated that RN #1 called 911. CNA #1 observed a clothes rope made of pants and polo shirts tied together extending down from the Third Floor to the ground. CNA #1 stated she normally worked with the resident once a day Monday thru Friday to assist with ambulation. She stated the resident always wore his coat and refused to take it off. The resident could walk independently but she assisted as needed. The resident preferred to stay in his room, and the resident was never aggressive with her. He told her that he had $10,000 in the bank and frequently mentioned that he wanted to leave the facility to get money out of the bank. During an interview on at approximately 10:30 AM, RN #1 stated she was the RN Supervisor for the 11:00 PM to 7:00 AM shift. She received a call on the supervisor's phone from CNA #1 at approximately 5:52 AM on CNA #1 was concerned of a possible homeless person lying in the king lot. RN #1 went out to assess the scene and realized it was a resident. RN #1 stated she did a quick assessment of the resident. The resident was lying on his right side, alert and responsive with garbled speech. RN #1 noted blood on his feet and socks. RN #1 stated that she called 911 and was told not to touch the resident. She noted a rope of clothing tied together extending from the Third Floor to the ground. RN #1 stated she did not receive any calls from staff on the Third Floor on the 11 :00 PM to 7:00 AM shift regarding any issues related to the resident. The resident was last seen by his assigned CNA (CNA #10) at 4:30 AM sitting on the side of his bed. RN #1 stated, the resident had removed nails multiple times from the window and had been throwing garbage out of the window. In discussing the incident with the incoming day shift staff on she spoke with RN #2 who stated the nails in the resident's windows had been replaced approximately 10 to 12 times. During an interview on at approximately 2:10 PM, CNA #2 stated she worked the 7:00 AM to 3:00 PM shift on the Third- Floor. The resident had' stated he felt as if he was being held captive and wanted to get out to get money from the bank. The resident appeared to be more upset after his court appearance on During an interview on at approximately 2:30 PM, RN #2 Unit Manager stated the resident had no previous accident] incidents prior to hanl?k nu ({pfqiunFnH 17134 . . Lou-ulna the incident on RN #2 completed the elopement risk assessment upon admission and determined the resident was at risk for elopement. The elopement plans she implemented was for the resident to be on the Third Floor locked unit where the elevator was coded (locked). The resident was at times pleasant and sometimes was agitated. He frequently stated that he had to go to the bank. She was aware that one time the resident was missing bolts from his window, and maintenance replaced the bolts. During an interview ?on at approximately 3:35 PM, the full time SW #2 stated she was familiar with the resident as she did the admission paperwork and follow up. Upon admission the resident was confused, agitated and said he wanted to go home. The resident had a temporary guardian and process was in place to make APS the permanent guardian. SW #2 stated, one time in morning report staff were told the resident had removed more than one bolt from his window. She did not ask the resident the reason for the bolt removal but requested a NP to see the resident. She stated that she did not tell the NP about the bolt removal and normally the NP would Speak to the RN Unit Manager (RN about the resident's history prior to an evaluation. She did not know the resident's screens were ripped but heard that the resident was throwing garbage out of his window. During an interview on at approximately 8:00 CNA #10 stated she worked full time on the 11 :00 PM to 7:00 AM shift. She was assigned to care for the resident on to The resident was not active during the shift and stayed in his room and she performed rounds every two hours on the resident. When she attempted to provide care to the resident he said, get out of here, I don't need anything. The last time she saw the resident was during rounds at 4:30 AM. She went into his room and he was sitting on the side of the bed. The resident stated, get out of my room. She never saw the resident tampering with his window and did not see a clothes rope in the room. She was not aware the resident had been removing bolts from his window. After the incident she was called by LPN #2 to come out to the king lot. LPN #2 told her not to touch the resident per the EMTs who were on the way. She said that after the shock of looking at the resident, she saw the clothes hanging out of the window. During an interview on at approximately 9:05 AM, LPN #2 stated she worked the 11:00 PM to 7:00 AM shift on the Third Floor. LPN #2 was not aware the resident was removing bolts from his window. She last saw the resident on between 1:00 AM to 2:00 AM, she stood in the resident's doorway and the resident was in the chair next to his bed. Later in the shift LPN #2 was told by the ambulation aide (CNA the Supervisor needed her outside due to a resident who eloped out of the window. During an interview on at approximately 10:15 AM, RN #2 Unit Manager stated she was never informed by maintenance staff the resident's window bolts were replaced 10 times. The issue was brought up in morning report one time, and she did not recall the date. RN #2 denied ever commenting to another RN (RN that the resident's bolts were replaced 10 to 12 times. if she had known the resident was removing window bolts she would have moved him to another room. RN #2 never asked the resident his reason for removing the bolts. RN #2 did not inform the NP that the resident had removed window bolts and they did not discuss the resident's desire to leave the facility. She discussed the resident's non-compliance with medications and treatments with the NP. Additionally, RN #2 stated that CNAs on the units are required to do every 2- hour rounds to check residents during their shift. 13:34 111912018 Nursing Home Inspection Details During an interview on at approximately 1:00 PM, NP #1 stated she had completed the initial history and physical examination She was not aware the resident was removing bolts from his window until after the incident on Additionally, she would have liked to have known the information to possibly change the care plan. During an interview on at approximately 1:15 PM, the Medical Director stated he had not seen the resident yet during his admission(NP had evaluated the resident. He was notified on of the resident's fall. He was not informed the resident had removed bolts from his window. Additionally, he would have liked to have known the information to possibly make a change in the resident's care plan. During an interview on at approximately 10:45 AM, NP #2 NP) stated she comes to the facility on ce a week to see resident's that are referred to her. NP #2 stated she would have expected the behavior of removing window bolts to be relayed to her, as she would consider this exit seeking behavior and would have recommended every 15-minute checks. During an interview on at approximately 3:15 PM, the Administrator stated he attended morning report every day. He recalled one time in morning report he had heard about the resident removing bolts from his window and throwing garbage out of the window. The Maintenance Director was going to add extra bolts to the window due to the garbage. He believed the issue was being addressed with the extra bolts. He also stated it was normal for a resident with dementia to comment that they want to leave. The nursing staff?s only complaint about the resident was he wore his jacket in hot weather. The Administrator was asked how he ensures problems brought up in morning report were addressed. He stated it was his expectation to keep the information flowing in detail to make a plan for safety. During an interview on at approximately 1:00 PM, RN #3 Second Floor Unit Manager stated it was brought up in morning report more - than once that maintenance had to replace the window in the resident's window. During a telephone interview on at approximately 4:00 PM, RN #4 First Floor Unit Manager stated she recalled the Maintenance Director stating in morning report the resident removed the window and threw garbage out of the window. She believed it was discussed twice and the Maintenance Director said that he had. to change the bolts several times. RN #4 recalled the Administrator being present at least once when this was discussed and the rest of the interdisciplinary team was present at morning report. RN #4 recalled that at report someone mentioned nailing the window shut. the-Hnrn?loc hnmeiinsnection detailiOEDH 19,34 I Iavrhv IU During interview on at 3:05 PM, RN #3 stated during morning report she jots down any issues on a piece of paper regarding her residents. She then makes a list of issues that need to be addressed. Depending on the issue she'may or may not discuss it with the DON and she would document the resolution to the issue on either a nursing progress note or on the nursing 24- hour report form. During a subsequent interview on at 1:00 PM, the Maintenance Director was asked if he attended the Quality Assurance (QA) meeting that included the'lDT, he statedthe meeting because I was meeting with an outside contractor. I had the Report of Concern with my paperwork and could've presented it but when I returned they started to talk about nursing issues. I dropped the ball. I could?ve presented it anyways. 20,34 11/9/2018 Nursing Home Inspection Details The ?nding is: Review of written notification to the New York State (NYS) Department of Health (DOH) dated 4/12/18 revealed that DON #1 was appointed as the full-time Director of Nursing effective 4/9/18. Review of the Statement of Deficiency (SOD) for the Recertification survey completed 4/30/18 to 5/8/18 revealed that 21 - health, four - criminal history record check, two - state, one - emergency preparedness and 25 life safety code de?ciencies were identi?ed. The plan of correction (POC) for the Recertification survey was due to be submitted to the NYS DOH on 6/3/18. During an interview on 6/8/18 at 3:15 PM, the (former) Administrator stated that DON #1 took a Personal Day on 5/18/18. On 5/23/18, she resigned then rescinded her resignation the same day. He stated that she came to work in the afternoon on 5/29/18 and stayed until 7:00 PM. Review of the Attendance Enterprise, the facility's payroll system, dated 5/13/18 to 5/26/18 revealed DON #1's last working day in the facility was 5/18/18. Review of written notification to the NYS DOH dated 5/21/18 revealed that DON #1 was appointed as the full-time DON at another facility effective 5/21/18. A telephone interview with DON #1 on 6/11/18 at 4:10 PM revealed her last day at the nursing facility was 5/18/18 and her ?rst day as DON at the new facility was 5/21/18. DON #1 stated she gave notice of her resignation to the (former) Administrator after the Recertification survey exit on 5/8/18 and texted her resignation to regional staff on 5/23/18. She stated she went to the facility on to drop off her keys and ID (identification), she was onsite for approximately one hour and left about 4:30 PM. She did not work on the P00 for the Recertification survey. Written notification from the facility to the NYS DOH dated 5/31/18 documented that a regional Quality Assurance RN was appointed as the Acting DON effective 5/30/18 and DON #2 was appointed as the full-time Director of Nursing effective 6/4/18. 34/34 FIOITIB UBIEIIS IJUIQUIU Based on interview and record review conducted during a Partial Extended survey (Complaint 780) completed on 6/15/18, the facility did not employ a Social Worker that has a Master's Degree in social work or is a Certi?ed Social Worker and has access through a contract on a full or part time basis. The ?nding is: Refer to 660 - Discharge Planning Process- Scope and Severity SIS Refer to 745 - Provisions of a Medically Related Social Worker? 8/8 Review of the Facility Survey Report dated 5/2/18 signed by the Administrator, revealed the facility employed a full time Social Worker with a Bachelor's degree in Social Work with two years of supervised social work experience in a health care setting working directly with individuals. Under the section CSW (Certi?ed Social Work) Number was left blank. During an interview on 6(12/18 at approximately 12:30 PM, part time Social Worker (SW) #1 and full time SW #2 revealed they both have a Bachelor's degree in social work. When asked if they were CSWs, both responded, no. When asked if they had access to a Social Worker with a Master's Degree or a CSW both Social Workers and 2) again responded, no. 415.5 FF11 a Hrs/7 days/Wk, Full Time DON REGULATION: 0483.35(b) Registered nurse Except when waived under paragraph or of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Except when waived under paragraph or of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Scope: Widespread Severity: Potential to cause more than minimal harm Citation date: June 15, 2018 Corrected date: August 8, 2018 TERMS lN BRACKETS HAVE BEEN EDITED TO PROTECT Based on' interView and record review conducted during a Partial Extended survey (Complaint 780) completed on 6/15/18, the facility did not designate a registered nurse to serve as the director of nursing on a full-time basis. Specifically, the 122?bed facility did not have a professional registered nurse (RN) designated to serve as the full-time director of nursing (DON) for approximately 11 days. 33(34 11/9/2018 Nursing Home Inspection Details Based on interview and record review conducted during a Partial Extended survey (Complaint 780) completed on 6/15/18, it was determined the facility did not maintain a quality assessment and assurance (QAA) committee that meets at least quarterly. In addition, the meetings did not include the Medical Director or a designee at those meetings. The ?nding is: 1. Review of the facility QAA committee meetings and attendance sheets revealed there was a QAA committee meeting held November 9, 2017. The next quarterly meeting was held April 27th, 2018. There was no documented evidence a quarterly meeting took place in February 2018. Additionally, the April 27, 2018 meeting did not include the Medical Director or a designee signature. There was a QAA meeting on June 1, 2018, this meeting also did not include the Medical Director or a designee. Review of the Statement of Deficiency (SOD) for the Recertification survey completed 4/30/18 to 5/8/18 revealed that 21 - health, four - criminal history record check, two - state, one - emergency preparedness and 25 - life safety code deficiencies were identi?ed. The plan of correction (POC) and the Directed Plan of Correction (DPOC) for the Recerti?cation survey was due to be submitted to the NYS DOH (New York State Department of Health) on 6/3/18. During a telephone interview on 6/15/18 at approximately 1:00 PM, the Medical Director stated, he was new to the nursing home and had not attended a QAA meeting but had plans to attend the next meeting. The Medical Director also stated he did not attend the June 1, 2018 QAA meeting. During an interview on 6/15/18 at approximately 2:10 PM, the Regional Administrator stated he could not produce any evidence the February 2018 QAA meeting took place and had no evidence the Medical Director attended the April 27, 2018. Additionally, he had no evidence the Medical Director attended the June 1, 2018 meeting, held as a result of the Plan of Correction required from the recent Recertification survey. He stated his expectation was QA meetings occur quarterly and include the Medical Director. ZT1N 415.5:Quality of Life REGULATION: Scope: Pattern Severity: Potential to cause more than minimal harm Citation date: June 15, 2018 Corrected date: August 8, 2018 32/34 Ivursmg home Details The Resident's Interdisciplinary Care Plan last reviewed by social work, documented the resident was alert and oriented times three (person, place and time), was independent with decision-making and placement was considered long term care. Approaches included to orient to facility and unit layout, maintain customary routine (pending discharge back home was crossed out) and allow time to adjust. SW to provide 1:1 PRN (one to one, as needed). Determination of Capacity dated and signed by the attending physician revealed, Based on my review it has been determined to a reasonable degree of medical certainty that the patient has the capacity to make health care decisions. During an interview on at 10:55 AM, Resident #2 stated, The nursing home hasn't planned my discharge and I wished they would. I miss my freedom, my cat and I used to have an apartment. I've seen the Social Worker maybe once since I've been here. I've never attended a care plan meeting. I walk with a walker but I do everything for myself. Review of the Social Work Progress Notes dated written by SW #1 documented a note regarding the resident's behavior and that Social Work was available 1:1 (one on one) PRN (as needed); and an untitled document dated regarding advanced directives. During an interview on at 12:30 PM, part time SW #1 and full time SW #2 revealed they visited or pop in on Resident #2 but did not document their visits. SW #2 stated although the resident was assessed no longer an elopement risk on he remained on the locked dementia unit because there were no private rooms available per his preference. In addition, SW #2 stated, ljust ?gured he was long term care because he didn't have family. There are no plans to discharge FF11 Committee REGULATION: 0483.75(g) Quality assessment and assurance. A facility must maintain a quality assessment and assurance committee consisting at a minimum of: The director of nursing services; (ii) The Medical Director or his/her designee; At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; The quality assessment and assurance committee must: Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary. Scope: Widespread Severity: Potential to cause more than minimal harm Citation date: June 15, 2018 Corrected date: August 8, 2018 . 31 {34 1119f2018 Nursing Home inspection Details During interview on at approximately 10:45 AM NP #2 NP) stated that she comes to the facility on ce a week to see resident's that are referred to her. The resident was referred to her to evaluate for adjustment to the facility. Prior to seeing the resident on she reviewed his medical record and spoke to multiple staff including the RN Unit Manager (RN about his behavior. NP #2 stated that she was aware that per a evaluation at the hospital the resident was deemed not to have capacity and had a She was told the resident was resistive to hands on care, refused medications and refused to take his coat off. Staff did not report aggressive behavior. Upon her assessment the resident stated that he did not want to be here, that he was hijacked and being held against his will. The resident showed her a $50 bill and told her he wanted to go to the store. NP #2 stated that during the evaluation the resident was agitated and had delusions but was not aggressive. She stated that she had to end the evaluation due to the resident's increasing agitation. She stated that she did not recommend any medications because she knew the resident had refused them. She stated that she recommended staff to monitor his behavior and to send him to the ER if he became a danger to himself or others. NP #2 stated that she was not informed by nursing home staff that the resident had been removing bolts from his window. She stated that she would expect the behavior of removing window bolts to be relayed to her as she would consider this exit seeking behavior and would have recommended every 15-minute checks. During an interview on at approximately 1:00 PM, RN #3 Second Floor Unit Manager stated it was brought up in morning report more than once that maintenance had to replace the window in the resident's window. During a telephone interview on at approximately 4:00 PM, RN #4 First Floor Unit Manager stated she recalled the Maintenance Director stating in morning report the resident removed the window and threw garbage out of the window. She believed it was discussed twice and the Maintenance Director said that he had to change the bolts several times. RN #4 recalled the Administrator being present at least once when this was discussed and the rest of the interdisciplinary team was present at morning report. In summary, there was a lack of documented social work involvement with the resident regarding his adjustment difficulty to the facility and the resident's continued expressions of wanting to leave the facility. There were five documented social work notes in the resident's medical record: and The note was the only note where SW evaluated/assessed/counseled the resident. The other notes were related to communicating with outside parties. The note was documented after the resident expired. SW #1 and SW #2 both stated on interview that they were aware of the resident's window bolt removal but neither one addressed the issue with the resident. SW 2 requested a NP to see the resident related to his adjustment issues but did not inform the NP about the resident's bolt removal. 2. Resident #2 was admitted to the facility's locked dementia unit on with Review of the MDS dated revealed the resident was moderately cognitively impaired, understands and was understood. The Risk of Elopement Assessment dated and signed by a Registered Nurse (RN) #5 revealed the resident was at risk for elopement and a Resident Monitoring Bracelet was applied to the left ankle. An Interval Nurse Practitioner (NP) Note dated revealed Chief complaint: Depression. Social Work (SW) informed provider that she just left resident's room where he was crying because he didn't know why he was brought here, no one told him he was coming here before it happened. Resident explains to provider that he prefers to take care of himself. He doesn't need anyone to clean him. He says he is lonely and has no one to talk to. The Risk of Elopement Assessment dated and signed by RN #2 revealed the resident was NOT at risk for elopement and the Resident Monitoring Bracelet was discontinued. The resident remained on the locked dementia unit. 30i34 Hull?v u met with the resident when he returned to the building to check for any items that may be used to harm himself or others. The resident had one butter knife, one spoon and a shaver. The resident appeared very hostile towards staff when they removed these items for his and others protection. SW notified the dietary department to switch the resident to plastic silverware until further notice. Review of a Report of Concern form dated signed by the Maintenance Director and Maintenance Supervisor revealed the maintenance department had installed a total of 10 window stops since the resident's arrival. The report stated the resident swore at the maintenance staff and stated I can do whatever I want. Maintenance proceeded to put another window stop in his window while he was out of the room. The report of concern revealed window st0ps were replaced on the following dates: and During an interview on at approximately 9:30 AM, the Maintenance Supervisor stated after the resident was admitted he noted a bolt missing from the resident's window during rounds and replaced it. The bolts were replaced 10 times over a 2 to 3 week period. He stated he told his boss, the Maintenance Director of the issue and many times his boss was with him when they replaced the bolts. Usually when they had to replace the bolts the CNA (certified nurse aide) would distract the resident and get him out of the room so they could replace the bolts. The Maintenance Supervisor stated the resident rarely was out on the unit and was angry because he felt he was kidnapped. He stated the screens were ripped in the room and resident would throw garbage out of the window. The last time the bolts were replaced was on During an interview on at 10:40 AM, the Maintenance Director stated the bolts (window stops) on the resident's window were replaced 10 times prior to and he mentioned the concern directly to the Unit Manager of the Third Floor (RN after the sixth time the bolt was replaced. He brought up the issue of the resident's window bolt removal in morning report on and with the Administrator, Director of Nursing (DON), RN #2 Unit Manager and the rest of the interdisciplinary team present. The team members told him they would discuss it. The Maintenance Director created a Report of Concern on and typed it on to cover himself, because after reporting the issue twice in morning report nothing was being done to address it. During an interview on at approximately 3:00 PM, the part time Social Worker (SW stated she was assigned to the resident's case along with the full time Social Worker. The resident was irate upon admission to nursing home and needed time to adjust. The resident often stated he wanted to leave. The resident had an upcoming court case regarding guardianship. When asked how often she saw resident to help assess his adjustment to the facility, she stated she saw him through pop in meetings to follow him which were not always documented. SW #1 stated, it was brought to the attention of staff in morning report the resident's window bolts had to be replaced approximately 10 times in the last two weeks. The resident ripped the screen and was throwing garbage out of the window. The reason the resident was removing the bolts was not identified and she did not ask the resident why he removed the bolts. Care planning for the bolt removal would be a nursing issue. At one point the resident was irate and told staff he had a weapon. Staff removed an electric shaver, spoon and fork from the resident. The NP met with the resident on due to increased agitation. During an interview on at approximately 3:35 PM, the full time SW #2 stated she was familiar with the resident as she did the admission paperwork and follow up. Upon admission the resident was confused, agitated and said he wanted to go home. The resident was offered a locked drawer for his money but he declined. SW #2 contacted APS who was pleased with the care. The resident had a temporary guardian and process was in place to make APS the permanent guardian. SW #2 stated, one time in morning report staff were told the resident had removed more than one bolt from his window. She did not ask the resident the reason for the bolt removal but requested a NP to see the resident. She stated that she did not tell the NP about the bolt removal and normally the NP would speak to the RN Unit Manager (RN about the resident's history prior to an evaluation. After the court appearance on the resident's care plan was changed to include plastic silverware only with his trays. She did not know the resident's screens were ripped but heard that the resident was throwing garbage out of his window. 29134 11f912018 Nursing Home Inspection Details 7:00 AM - 3:00 PM shift: increased behavioral issues, increased aggression towards therapy, yelling at PT (physical therapy). - 3:00 PM - 11 :00 PM shift: no behavior issues this shift but stated I need to go to bank calmly. The Interdisciplinary Care Plan last updated on revealed the resident had no care plan developed for elopement that included measurable goals. The care plan did not include a method to observe the resident's whereabouts. In addition, the care plan documented the resident was non-compliant with personal care including showers, grooming, oral care, dressing and clothing changes. The resident refused medications, treatments and labs (blood work). The care plan also documented the resident believed he was in jail, self-isolated himself, and preferred to keep his door shut.' A social work note dated written by SW #1 documented Adult Protective Services (APS) was involved in the resident's care and fighting for guardianship on The note stated SS (Social Services) will continue to be available 1:1 (one to one) as needed. A Evaluation dated written by NP #2 revealed resident was being seen for an initial consultation at the staff's request. The resident was previously homeless and deemed to lack capacity while hospitalized therefore was placed in long term care. The note documented staff reported the resident refused all hands?on care, refused medications; therefore, the medications had been discontinued. The resident refused to attend to his personal hygiene and spent most of the day in his room watching television (TV) with his coat on. The resident reported he was angry because he felt he was being held prisoner in the facility. The resident stated, I?m doing bad because I can't go anywhere. I can't go to the bank or store. I can only watch TV all day. I didn't do no crime so I don't know why they hijacked me and put me here. The resident was upset because he had not received his Social Security checks in months and stated the facility was holding him against his will and robbing him of his money. During the evaluation the resident told NP #2 to get out of the room. NP #2 documented the resident's verbal aggression continued to escalate so she concluded the consultation. NP #2's assessment was The treatment recommendation stated the resident was unlikely to be agreeable to medication management. Furthermore, if the resident became a danger to self and/or others, send to emergency department (ED) for evaluation and stabilization. A social work note dated written by SW #1 documented on this day she had spoken to two different parties regarding the resident's upcoming court case. SW #1 spoke to the hospital attorney regarding the resident not having capacity and not able to make decisions for himself. SW #1 also spoke to the attorney representing the resident. SW #1 explained to both parties at this time a neuro exam had not been completed due to the fact the resident does not do well when on transports and was combative upon arrival to facility. It was in the best interest of the resident to stay within the facility expect when he needs to appear at court where the resident will be escorted. SW explained to both individuals that the resident was non?compliant while in the facility and refusing all meds. Resident often fixates on money and carries an unknown amount on him. The resident would like to leave the facility but resident is currently homeless and has no known family members. SW was unable to determine capacity but the resident does not score well on the BIMs (Brief interview for mental status) which was usually a 5 leading to the belief the resident had cognitive impairment. Resident eats and sleeps but does not come out of him room often. Resident keeps a heavy coat on and refuses to take it off. 88 (social service) will talk with other staff to determine if an outing was needed to be seen for a neuro (neurological) consult. 88 (social services) will be available for 1:1 (one to one) as needed. A SW note dated written by SW #2 documented, SW #2 received a call from the hospital attorney with an update on the resident's court appearance (of The resident was very non-compliant during his visit and refused to walk through the metal detector, which led them to - believe the resident had something on him. She (the attorney) noted the resident tried to escape every chance he got but his escort was able to re-direct him. For his next court date, they would like to hold it within the facility to avoid this happening again. SW #2 and the nursing supervisor 28/34 IO Nursmg Home Inspecnon Scope: Pattern Severity: Potential to cause more than minimal harm Citation date: June 15, 2018 Corrected date: August 8, 2018 TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT Based on interview and record review conducted during 3 Partial Extended survey (Complaint 780) completed on the facility did not provide medically?related social services to attain or maintain the highest practicable physical, mental and well-being of each resident for two (Resident 2) of three residents reviewed for medically-related social services. Speci?cally, there was a lack of Social Work (SW) visits for a resident known to remove window blots NAMED and expressed a strong desire to be discharged (Resident Additionally, there was a lack of Social Work visits for a resident residing on a locked unit, no longer an elopement risk, and deemed by the physician to have capacity to make their own health care decisions (Resident The findings are: The Social Workerjob description revised documented job duties included to maintain frequent contact with each resident to monitor behaviors/concerns and to document pertinent information regarding residents as required by the Social Work Department. 1. Resident #1 was admitted to the facility on with Review of the Minimum Data Set a resident assessment tool) dated revealed the resident had severe cognitive impairment, usually understands and was understood. Review of a Social Work Progress Note dated written by Social Worker (SW) #2 revealed the resident was admitted from the hospital. The resident was alert and oriented with confusion. The resident had no MOLST (medical orders for life sustaining treatment). The note documented staff was to provide information to the temporary guardian regarding advance directives. The resident had been living in a homeless shelter and had no home. The resident was fixated on money and not wanting to be in the facility. Review of Nursing Progress Notes revealed the following: at 3:00 PM written by Licensed Practical Nurse (LPN) the resident had refused all hands- on care, blood pressure and medications. The resident stated, I'm going out of here. at 3:00 PM written by LPN the resident had refused all medications and stated, I want to get out, I did not sign myself in here, I'm not a prisoner. Review of nursing 24-hour reports revealed the following: 7:00 AM - 3:00 PM shift: agitated wanting to leave, refused skin check. - 7:00 AM - 3:00 PM shift: Resident alert, ambulating ad lib, refused all meds, stated get the (explicit foul language) away. 7:00 AM - 3:00 PM shift: Resident alert with confusion, refused all meds, refused to remove coat, I want out of here. 27134 11/9/2018 Nursing Home Inspection Details Scope: Isolated Severity: Potential to cause more than minimal harm Citation date: June 15, 2018 Corrected date: August 8, 2018 TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT Based on interview and record review conducted during a Partial Extended survey (Complaint 780) completed on 6/15/18, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the resident's personal funds deposited with the facility. Specifically, one (Resident of three residents reviewed for personal funds, the facility did not process the application for the facility to be the resident's Social Security representative payee timely, which resulted in a delay of five or greater months in getting access to their funds. The ?nding is: 1. Resident #2 was admitted to the facility on and has Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/25/18revealed the resident is moderately cognitively impaired, understands and is understood. During an interview on 6/12/18 at 10:55 AM, Resident #2 stated, I haven't seen a penny from my account since I was admitted . Review of Resident #2's application for the facility to be the resident's Social Security representative payee revealed the attending physician signed off on the application on 2/13/18; five months after the resident's admitted . Review of Resident #2's Funds Ledger for his personal funds account revealed the resident had $150.00 in the personal account as of 6/6/18. During an interview on 6/12/18 at 12:30 PM, the Social Worker (SW) #2 stated there was a delay in the resident's paperwork and his moneyjust become available. He'll be able to access his $50.00 allowance going back to September 2017 when he was admitted . During an interview on 6/14/18 at approximately 2:30 PM, the facility attorney stated SW #2 started the application but neglected to have the physician ?ll it out until 2/13/18. The resident as of 6/6/18 may begin to make withdrawals. FF11 of Medically Related Social Service REGULATION: 0483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and well-being of each resident. home/inspection_detaiI/OEDH 25/34 I Inn-Lu Iu UULUIIE During an unannounced visit to the facility on at approximately 8:30, DOH surveyors were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The ?rst interview was not conducted until approximately 12:30 PM, when the staff attorney arrived at the facility. A total of five interviews were conducted ending at approximately 4:15 PM. An email sent to the DOH surveyor dated 6/1208 at 4:30 PM revealed, I understand you have left the facility for the day, and indicated to a staff member you have no plans to return tomorrow. As you know, I am the attorney for all Emerald South individual employees who you may wish to interview in the course of this inquiry. Let me reiterate my request that you contact me to schedule any further such interviews. I will c00perate with ybu to produce those witnesses for interview as soon as they are available, and will to the maximum of my ability adjust my own schedule to accomplish that. If you are unable to agree with that process, please share this message with your superiors or your counsel so that I can address this with those parties. Thank you for your attention to this matter. During an unannounced visit to the facility on at approximately 9:15 AM, DOH surveyors were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The ?rst interview was not conducted until approximately 2:50 PM when the staff attorney arrived at the facility. A total of four interviews were conducted ending at approximately 3:25 PM. 400.2 FF11 of Personal Funds REGULATION: The resident has a right to manage his or her ?nancial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds. The facility'must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a ?duciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section. (ii) Deposit of Funds. (A) In general: Except as set out in paragraph of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest- bearing account, or petty cash fund. (B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident?s share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund. 25134 1179/2018 Nursing Home InSpection Details 400.2 TERMS IN BRACKETS HAVE BEEN TO PROTECT Based on interview and record review conducted during the Partial Extended survey (Complaint 780) completed on 6/15/18, the facility impeded the Department's ability to conduct unannounced inspections of the facility, and failed to furnish to the department such reports and information as it may require to effectuate inspection and/or investigation. The facility impeded the New York State Department of Health (DOH) by obstructing access of nursing home staff interviews which delayed the DOH's investigation. The ?nding is: Public Health Law (PHL) 2803(1)(a) provides that the commissioner shall have the power to inquire into the operation of hospitals and to conduct periodic inspections of facilities, including the power to conduct visits as needed to determine compliance with applicable statutes and regulation, and to determine whether violations and deficiencies have been corrected. 2803(1)(a) requires that such inspections be unannounced. PHL 2803(4) provides that at the request ofthe Commissioner, hospitals shall furnish to the department such reports and information as it may require to effectuate the provisions of (Article 28). Review of a Dear Administrator letter (DAL) dated 4/30/10 revealed, New York courts have held that facilities licensed under Article 28 must always be open to Health Department inspections designed and planned to ensure that the care and protection mandated by law are actually being furnished. Uzzillia v. Comm'r of Health, 47 492, 497 (2d Dept 1975), appeal dismissed, 37 777 (1977). As such, licensed facilities may not require the Department to make appointment, may not delay an inspection to await the clearance of counsel, and may not delay an inspection pending completion of administrative hearings. Id. In other words, the act of placing conditions on Department representatives in the course of an inspection or investigation is deemed a de facto denial of access. 1. During an unannounced visit to the facility on at approximately 8:30 AM, DOH surveyor interviewed the acting Director of Nursing DON at approximately 9:30 AM, a Registered Nurse (RN at 10:30 AM and a certi?ed nurse aide (CNA at 11:20 AM. At approximately 12:00 PM, the surveyor was informed by the facility attorney that interviews would be halted until the staff attorney could be present. Between approximately 2:00 PM and 3:00 PM, after arrival of the staff attorney, one interview was conducted. During an unannounced visit to the facility on at approximately 8:30 AM, DOH surveyors were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The ?rst interview was not conducted until approximately 3:10 PM when the staff attorney arrived at the facility. A total of three interviews were conducted, ending at approximately 4:15 PM. During an unannounced visit to the facility on at approximately 8:00 AM, six interviews were conducted in the presence of the staff attorney between approximately 8:10 AM and 10:15 AM. interviews were then halted as the staff attorney had to leave the facility for another obligation. Between approximately 1:40 PM and 3:40 PM upon arrival of the staff attorney, five interviews were conducted. During an unannounced visit to the facility on at approximately 8:30 AM, DOH surveyors were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The ?rst interview was not conducted until approximately 2:00 PM when the staff attorney arrived at the facility. A total of three interviews were conducted ending at approximately 4:15 PM. 24f34 I nun-aunt, Iv-uv unannounced. PHL 2803(4) provides that at the request of the Commissioner, hospitals shall furnish to the department such reports and information as it may require to effectuate the provisions of (Article 28). Review of a Dear Administrator letter (DAL) dated 4/30/10 revealed, New York courts have held that facilities licensed under Article 28 must always be open to Health Department inspections designed and planned to ensure that the care and protection mandated by law are actually being furnished. Uzzillia v. Comm'r of Health, 47 492, 497 (2d Dep't 1975), appeal dismissed, 37 777 (1977). As such, licensed facilities may not require the Department to make appointment, may not delay an inspection to await the clearance of counsel, and may not delay an inspection'pending completion of administrative hearings. Id. In other words, the act of placing conditions on Department representatives in the course of an inspection or investigation is deemed a de facto denial of access. 1. During an unannounced visit to the facility on at approximately 8:30 AM, DOH surveyor interviewed the acting Director of Nursing DON at approximately 9:30 AM, a Registered Nurse (RN at 10:30 AM and a certified nurse aide (CNA at 11:20 AM. At approximately 12:00 PM, the surveyor was informed by the facility attorney that interviews would be halted until the staff attorney could be present. Between approximately 2:00 PM and 3:00 PM, after arrival of the staff attorney, one interview was conducted. During an unannounced visit to the facility on at approximately 8:30 AM, DOH surveyors Were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The ?rst interview was not conducted until approximately 3:10 PM when the staff attorney arrived at the facility. A total of three interviews were conducted, ending at approximately 4:15 PM. During an unannounced visit to the facility on at approximately 8:00 AM, six interviews were conducted in the presence of the staff attorney between approximately 8:10 AM and 10:15 AM. Interviews were then halted as the staff attorney had to leave the facility for another obligation. Between approximately 1:40 PM and 3:40 PM upon arrival of the staff attorney, ?ve interviews were conducted. During an unannounced visit to the facility on at approximately 8:30 AM, DOH surveyors were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The first interview was not conducted until approximately 2:00 PM when the staff attorney arrived at the facility. A total of three interviews were conducted ending at approximately 4:15 PM. During an unannounced visit to the facility on at approximately 8:30, DOH surveyors were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The ?rst interview was not conducted until approximately 12:30 PM, when the staff attorney arrived at the facility. A total of five interviews were conducted ending at approximately 4:15 PM. An email sent to the DOH surveyor dated 6/12/[8 at 4:30 PM revealed, I understand you have left the facility for the day, and indicated to a staff member you have no plans to return tomorrow. As you know, i am the attorney for all Emerald South individual employees who you may wish to interview in the course of this inquiry. Let me reiterate my request that you contact me to schedule any further such interviews. I will cooperate with you to produce those witnesses for interview as soon as they are available, and will to the maximum of my ability adjust my own schedule to accomplish that. if you are unable to agree with that process, please share this message with your superiors or your counsel so that i can address this with those parties. Thank you for your attention to this matter. During an unannounced visit to the facility on at approximately 9:15 AM, DOH surveyors were informed by the facility attorney that staff interviews would not commence until the staff attorney was available. The ?rst interview was not conducted until approximately 2:50 PM when the staff attorney arrived at the facility. A total of four interviews were conducted ending at approximately 3:25 PM. 23i34 11l912018 Nursing Home Inspection Details FF11 wl Fed/StatelLocl Law/Prof REGULATION: 0483.70(a) Licensure. A facility must be licensed under applicable State and local law. 0483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. 0483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 154). Violations of such other provisions may result in a finding of non-compliance with this paragraph. Scope: Pattern Severity: Potential to cause more than minimal harm Citation date: June 20, 2018 Corrected date: August 8, 2018 TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT Based on interview and record review conducted during the Partial Extended survey (Complaint 780) completed on 6/15/18, the facility impeded the Department's ability to conduct unannounced inspections of the facility, and failed to furnish to the department such reports and information as it may require to effectuate inspection and/or investigation. The facility impeded the New York State Department of Health (DOH) by obstructing access of nursing home staff interviews which delayed the DOH's investigation. The finding is: Public Health Law (PHL) 2803(1)(a) provides that the commissioner shall have the power to inquire into the operation of hospitals and to conduct periodic inspections of facilities, including the power to conduct visits as needed to determine compliance with applicable statutes and regulation, and to determine whether violations and de?ciencies have been corrected. 2803(1)(a) requires that such inspections be 22i34