Initial Comments:
A focused fundamental survey was conducted on January 10, 11, 12, 13, and 14, 2022 to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was 34 and the sample consisted of six individuals. Two deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on staff interview and investigation report review, it was determined that facility staff failed to report an allegation of a potential rights violation and one allegation of potential physical abuse in a timely manner to facility administration for two individuals residing at the facility. (Individuals #3 and #4)
Findings included:
A. Individual #3
1. Review of a facility investigation and staff interview revealed an incident of a potential rights violation had occurred on February 26, 2021 at approximately 6:00 a.m. The allegation was not reported to facility administration until February 27, 2021 at approximately 7:15 p.m.; one day after it was observed. This potential rights violation was confirmed by facility investigation
B. Individual #4
1. Review of a facility investigation and staff interview revealed an incident of potential physical abuse had occurred on July 1, 2021, at approximately 11:15 a.m. The allegation was not reported to facility administration until July 2, 2021 at approximately 3:00 p.m.; one day after it was observed. This allegation of physical abuse was not confirmed by facility investigation.
C. On January 15, 2022 at 10:00 am, the facility Assistant Vice-President (AVP) was interviewed. The AVP confirmed the above-mentioned information.
Plan of Correction:W153: Staff Treatment of Clients:
The facility failed to report an allegation of a potential rights violation in a timely matter. The potential rights violation involved two individuals, Individual #3 and #4.
On 2/26/21 at 6am, an individual was found in bed with Individual #3, and the incident was not reported until 2/27/21. This incident was determined to be "confirmed" as a rights violation.
On 7/1/21, during an investigation of alleged physical abuse that was "timely", the "target" then made an allegation toward a co-worker from an alleged incident from the day before. The result of this investigation "not confirmed.
To address the deficient area identified in W153, the facility will implement the following corrective measures and systematic changes to eliminate the re-occurrence of the deficient practice:
1. All staff will in-servicing on the Incident Management policy as it relates to the reporting of allegations of abuse, neglect and mistreatment of individuals.
2. All staff will receive in-servicing on the Emergency Contact List which identifies all managers, supervisors, and clinicians office telephone numbers and home/cell phones for after hour contacts in the event of an alleged incident.
3. All staff will be in-serviced on the Manager and Clinical Staff Schedules that allows most incidents to be investigated while Point Persons and Certified Investigators are on-duty.
4. All staff will be in-serviced on the "profiles" of Individual #3, #4, and the "victim" of #3 in order to better understand their respective behaviors to potentially thwart the inappropriate behaviors from occurring.
The facility will implement written "post-tests" following in-servicing as a record of monitoring the progress of the plan of correction, and will monitor corrective actions in monthly Incident Management meetings.
The facility will also update the "Special Needs" lists for LV 421-422-423 and provide in-service training to all staff. The "Special Needs" provides a "snap shot" of important "needs" that residents have that ensure their health, welfare and safety. These "Special Needs" address whom requires assistance in ambulation such as "contact guard" or "shadowing", enhanced supervision at meals, field of vision. Together, in-service training in Incident Management policy and "Special Needs" will address "all others who have the potential to be affected by the deficient practice" identified in W153.
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W153: Staff Treatment of Clients:
The Assistant Vice president is ultimately responsible for completion of the plan of correction and to ensure that the deficient practice does not re-occur. However, the plan of correction will be completed via a coordinated effort by the Assistant Director and Program Manager with their respective team of Unit Manager, Supervisors, QIDP, Program Specialist and Staff Training Coordinator. Records of the plan of correction will be maintained in the administrative office.
483.430(e)(4) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to implement the individual program plans for each client for whom they are responsible.
Observations:
Based on staff interview and incident report review, it was determined that the facility failed to ensure staff demonstrated the skills necessary to implement the Individual Program Plan for two individuals residing in the facility. (Individuals #1 and #2)Findings included:
A. Individual #1
A review of facility incident / investigations was conducted on January 11 - 14, 2022. This review revealed that from April 6, 2021 to October 1, 2021 Individual #1 was involved in seven incidents while under general staff supervision. Four of the incidents resulted in injuries for the individual. The incidents are as follows:
1. A review of a facility investigation report regarding an incident of alleged potential physical abuse was conducted on January 11, 2022. This review revealed that on April 6, 2021 at approximately 3:00 p.m. one facility staff placed Individual #1 on the commode without the assistance of another facility staff. Further review revealed Individual has a diagnosis of Osteoporosis, high risk for falls and subsequent fractures and that two staff are to be present for transfers. In addition, the review revealed Individual #1 did not experience any ill effects as result of the above-mentioned incident. The investigation findings determined the allegation of potential abuse to be inconclusive, However, the investigation determined that facility staff failed to follow Individual #1's Individual Support Plan as written.
2. On August 13, 2021, at approximately 6:15 p.m., while seated on the commode, leaned to the right and fell onto the corner of the bathroom stall seat. Individual #1 did not experience ill effects as a result of this incident.
3. On August 15, 2021 at approximately 3:43 a.m., while being transfer from a chair to a couch, Individual #1 went down to his knee. Individual #1 sustained a carpet burn to the right knee as result of the incident.
4. On August 27, 2021, at approximately 4:10 a.m., facility staff attempted to place Individual #1's socks on while Individual #1 was seated on the commode. Individual #1 rolled off the commode hitting his head on the wall. Individual #1 sustained two scratches to the nose as a result of the incident. Evaluation and treatment were provided by facility staff.
5. On September 23, 2021 at approximately 5:30 a.m., facility staff sat Individual #1 up in bed, Individual #1 fell over and hit his head. Individual #1 sustained a 3 cm laceration to the head as a result to the incident. Evaluation and treatment were provided by facility nursing staff. 6. On September 29, 2021 at approximately 8:00 p.m. while facility staff were putting Individual #1's shoes on, Individual #1 fell off the bed, hitting his head on the floor. Individual #1 sustained a one-and-a-half-inch laceration to the top right side of his head. Evaluation and treatment were provided by facility nursing staff.7. On October 1, 2021, at approximately 11:15 a.m. Facility staff into the living area and found Individual #1 on the floor. Individual #1 did not experience any ill effects as a result of the incident.
B. Individual #2
1. Review of a facility investigation report revealed that on March 16, 2021 at 2:40 p.m. while Individual #2 was on the company van being transferred from day program his wheelchair tipped over and he fell backward, hitting the back of his head. Individual #2 was transported to the hospital where he received treatment for a head contusion. A certified investigation was completed as a result of the incident.
2. Review of the facility investigation revealed that the staff in question had failed to ensure that the "four tie-downs" for the wheelchair had been properly secured prior to the van transport. This failure resulted in the fall and Individual #2 ' s subsequent head contusion. The investigation determined that target staff failed to follow the plan of care and provide necessary supports for Individual #2's safe transport.
C. On January 15, 2022 at 10:00 am, the facility Assistant Vice-President (AVP) was interviewed. The AVP confirmed the above-mentioned information.
Plan of Correction:W194: Staff Training Program:
This deficient area identifies that the facility failed to ensure that staff demonstrated the necessary skills to effectively implement the Individual Program Plans for two individuals.
Individual #1 has enhanced supervision due to a high risk for falls and history of injuries, slight such as bumps, scratches to more severe such as fractures. Despite enhanced supervision, incidents continue to occur.
Individual #2 sustained a minor injury, yet transported to the hospital emergency room when his wheelchair tipped and fell during transport. The investigation that ensued resulted in the determination that "tie-downs" to secure the wheelchair were not adequately secured resulting in the tipping of the wheelchair. Fortunately, Individual #2 did not sustain any major injury.
To address the deficient area identified in W194, the facility will implement the following corrective actions and systematic changes to ensure that the deficient practices do not re-occur:
1. The QIDP will conduct a Interdisciplinary Team Meeting to address Individual #1's needs to ensure that ADL activities can be safely administered without injury. The meeting will be recorded as a document in the Individual #1's record. The Program Manager, Unit Manager and supervisors will ensure that all staff are in-serviced on the results of the meeting as it pertains to Individual #1's treatment plan.
An Individual #1's "profile" will be developed through the QIDP, Program Specialist, and residential supervisors and staff......"What to Know About Individual #1". The intent is to increase the overall awareness of staff to Individual #1's physical, behavioral and emotional needs to better address his needs I a safe manner.
To address "all other individuals who could be adversely affected by the deficient practice", the "Special Needs" list for LV 421-422-423 will be updated and staff will be in-serviced.
Individual #2: as a result of Individual #2's fall in his wheelchair due to incorrect wheelchair "tie downs", all residential staff will be re-in-serviced on van tie down procedures through coordination of the unit supervisors and the Staff Training Coordinator. Residential staff who have "good skills" can be used as a train-the-trainer method to ensure timely training. All staff should have at least (1) refresher in-service/demonstration in 2022, making for at least (2) documented trainings/demonstrations.
The Assistant Vice president is ultimately responsible for completion of the plan of correction and to ensure that the deficient practice does not re-occur. However, the plan of correction will be completed via a coordinated effort by the Assistant Director and Program Manager with their respective team of Unit Manager, Supervisors, QIDP, Program Specialist and Staff Training Coordinator. All progress related to the the plan of correction will be documented within the monthly Incident Management meeting. Records of the plan of correction will be maintained in the administrative office.
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